Late Venous Thromboembolism Chemoprophylaxis and Increased Risk of Deep Venous Thrombosis, Pulmonary Embolism, and Mortality in Patients with Traumatic Spinal Injury.

Autopsy and retrospective studies [1–4] lead to believe that patients hospitalized for acute medical illness are at higher risk of deep venous thrombosis (DVT) and pulmonary embolism (PE) and that anticoagulant treatment was, therefore, necessary to prevent such vascular outcomes. Interventional trials consistently showed that prophylaxis with anticoagulants reduces the risk of composite endpoints of DVT, PE and DVT-related death in patients hospitalized for acute medical illness while no effect has been detected for total mortality [5]. These results prompted to recommend the use of anticoagulant prophylaxis in patients hospitalized for acute medical illness [6], but despite this, there is a large underuse of anticoagulant prophylaxis in the medical wards of hospitals [7, 8]. The scarce use of anticoagulants in acutely ill medical is almost evident in a multicenter clinical registry (The REPOSI study) performed by investigating patients hospitalized in Italian divisions of internal medicine [9]. Thus, Marcucci et al. [9] included 1,121 acutely ill medical patients and followed them up during the hospital stay and until 3 months after hospital discharge. Patients included were very old, with a mean age of 82 years; males and females were equally distributed. Among 1,121 patients, 171 (15.2 %) were treated with thromboprophylaxis (TP) including low molecular weight heparin (n = 158), unfractionated heparin (n = 4) and fondaparinux (n = 9). Administration of anticoagulants was unrelated to the current guidelines of this setting as only 14.9 % of treated patients met the criteria of ACCP 2004 guidelines [10]. Among the putative risk factors considered, impaired global performance, as assessed by Barthel index [11], length of hospital stay and acute respiratory failure were independent predictors of TP during the hospitalization. Because the rate of patients treated with TP was low, the study offers an interesting chance to appreciate the rate of DVT in a relatively large population of acutely ill medical patients. Figure 1 depicts the rate of DVT in patients treated or not with TP. During the hospital stay among 950 untreated patients, DVT was diagnosed in 5 (0.5 %) while 1 (0.6 %) DVT was observed in the 171 treated patients; in the 3-month follow-up only three untreated and one treated patients experienced DVT. Taking into account the entire follow-up, 8 (0.8 %) untreated and 2 (1.1) treated patients experienced DVT. Pulmonary embolism was detected in two patients with DVT (one treated and one untreated) only after hospital discharge. We have recently reviewed the incidence of DVT in the interventional trials with anticoagulants performed in acutely ill medical patients [12]. The rate of DVT was quite different if symptomatic or asymptomatic events were separately considered [12]. Thus, asymptomatic DVT was much more frequent compared to symptomatic ones with a large variation ranging as high as 28 % to as low as 2.3 % with an average of 4.7 % [12]. The rate of symptomatic DVT was much less with values from as high as 1.5 % to as low as 0.8 % and an average of 0.99 % [12]. Despite Marcucci et al. [9] reported the incidence of only symptomatic DVT, we believe that these data add important news on this topic. Thus, they found that during the hospital stay the rate of symptomatic DVT was a little bit less (0.5 %) compared to This comment refers to the article available at doi:10.1007/s11739-013-0944-8.

Treatment of Varicose Veins Affects the Incidences of Venous Thromboembolism and Peripheral Artery Disease

[Figure: see text].

To the Editor: The recent review by Kelly et al1 generally takes a balanced view of the evidence cited but surprisingly omits some very important evidence. There is good evidence from several sources that antiplatelet agents (most of the evidence comes from trials of aspirin) are effective and safe in preventing deep venous thrombosis (DVT) and pulmonary embolism (PE) in a wide variety of patients at high risk of venous thromboembolism.2 3 A systematic review of the randomized trials available up to 1994, including a total of approximately 9000 patients, showed that antiplatelet agents (chiefly aspirin) significantly reduced the risk of DVT by 39% and PE by 64%.2 3 Some clinicians were not persuaded by the evidence from the Antiplatelet Trialists’ meta-analysis, so a large-scale trial was established to confirm or refute these results. The Pulmonary Embolism Prevention (PEP) trial sought to evaluate the effects of low-dose aspirin in the prevention of pulmonary embolism and deep vein thrombosis in patients undergoing surgery for hip fracture.4 The trial randomized 13 356 patients to aspirin or placebo. Allocation to aspirin significantly reduced the odds of PE by 43% (95% CI 18 to 60) and symptomatic DVT by 29% (95% CI 3 to 48).4 The Cochrane review by Gubitz et al5 (not cited by Kelly) identified 8 trials of antiplatelet therapy in patients with acute ischemic stroke that reported effects on venous …

Risk of pulmonary embolism and deep venous thrombosis in patients with asthma: a nationwide case-control study from Sweden.

Thalidomide Therapy and Deep Venous Thrombosis in Multiple Myeloma

Low-molecular-weight heparin (LMWH) is widely used for venous thromboembolism chemoprophylaxis following injury. However, unfractionated heparin (UFH) is a less expensive option. We compared LMWH and UFH for prevention of posttraumatic deep venous thrombosis (DVT) and pulmonary embolism (PE). Trauma patients 15 years or older with at least one administration of venous thromboembolism chemoprophylaxis at two level I trauma centers with similar DVT-screening protocols were identified. Center 1 administered UFH every 8 hours for chemoprophylaxis, and center 2 used twice-daily antifactor Xa-adjusted LMWH. Clinical characteristics and primary chemoprophylaxis agent were evaluated in a two-level logistic regression model. Primary outcome was incidence of DVT and PE. There were 3,654 patients: 1,155 at center 1 and 2,499 at center 2. The unadjusted DVT rate at center 1 was lower than at center 2 (3.5% vs. 5.0%; p = 0.04); PE rates did not significantly differ (0.4% vs. 0.6%; p = 0.64). Patients at center 2 were older (mean, 50.3 vs. 47.3 years; p < 0.001) and had higher Injury Severity Scores (median, 10 vs. 9; p < 0.001), longer stays in the hospital (mean, 9.4 vs. 7.0 days; p < 0.001) and intensive care unit (mean, 3.0 vs. 1.3 days; p < 0.001), and a higher mortality rate (1.6% vs. 0.6%, p = 0.02) than patients at center 1. Center 1's patients received their first dose of chemoprophylaxis earlier than patients at center 2 (median, 1.0 vs. 1.7 days; p < 0.001). After risk adjustment and accounting for center effects, primary chemoprophylaxis agent was not associated with risk of DVT (odds ratio, 1.01; 95% confidence interval, 0.69-1.48; p = 0.949). Cost calculations showed that UFH was less expensive than LMWH. Primary utilization of UFH is not inferior to LMWH for posttraumatic DVT chemoprophylaxis and rates of PE are similar. Given that UFH is lower in cost, the choice of this chemoprophylaxis agent may have major economic implications. Prognostic and epidemiological, level II; Therapeutic, level III.

Deep venous thrombosis (DVT) and pulmonary embolus (PE) remain an important cause of morbidity and mortality after THA and TKA. Prior recommendations have advocated for more aggressive prophylaxis for patients with obesity, whereas the evidence supporting these recommendations is conflicting and often based on underpowered studies. (1) What is the association between obesity and DVT and PE after primary and revision THA and TKA? (2) Is there a body mass index (BMI) threshold beyond which DVT and PE risk is elevated? We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2008 to 2016 to evaluate the reported 30-day rates of DVT, PE, and combined venous thromboembolism (VTE) after primary THA, primary TKA, revision THA, and revision TKA according to BMI as a continuous variable and a categorical variable as defined by the World Health Organization cutoffs for underweight, normal weight, overweight, and obesity. This database is risk-adjusted and designed to capture complications after surgery, thus making it ideal for this study. The diagnosis of DVT and PE is included in the ACS-NSQIP database for any DVT or PE requiring treatment. Proximal versus distal DVT is not specified within the database. Multivariate logistic regression was performed to determine if obesity was independently associated with DVT and PE risk by controlling for age, sex, race, American Society of Anesthesiologists score, diabetes, hypertension, smoking status, general anesthesia, and hypoalbuminemia. After controlling for potential confounding variables such as medical comorbidities and procedure type, patients undergoing primary and revision THA and TKA with World Health Organization classification as underweight (BMI < 18.5 kg/m), overweight (BMI 25-29.9 kg/m), Class I obese (BMI 30-34.9 kg/m), Class II obese (BMI 35-39.9 kg/m), or Class III obese (BMI ≥ 40 kg/m) did not demonstrate an association with increased risk of DVT compared with patients classified as normal weight (BMI 18.5-25 kg/m). Compared with patients undergoing primary THA classified as normal weight, the risk of PE was elevated in patients with Class II obesity (odds ratio [OR], 2.36; 95% confidence interval [CI], 1.23-4.50; p = 0.009) and all heavier categories. Compared with patients undergoing TKA classified as normal weight, the risk of PE was elevated in patients classified as overweight (OR, 1.56; 95% CI, 1.03-2.36; p = 0.035) and all heavier categories. This large administrative database study suggests that patient classification as overweight or obese is associated with increased risk of development of PE but not DVT after primary THA or TKA. Because aggressive pharmacologic anticoagulation regimens can decrease the DVT rate but have not been shown to affect the rate of PE or death, the data do not currently support increased anticoagulation in patients with obesity without other risk factors for VTE undergoing THA or TKA. Additional studies are required to refine VTE prophylaxis protocols to reduce PE risk while maintaining acceptable postoperative bleeding risk. Level III, therapeutic study.

To (1) identify trends in the rates of deep venous thrombosis (DVT) and pulmonary embolism (PE) and (2) calculate the additional incremental inpatient cost and length of stay associated with venous thromboembolism (VTE) after hip fracture surgery. Retrospective database analysis. Hospital discharge data. A total of 838,054 patients undergoing operative treatment of hip fractures in the National Inpatient Sample from 2003 to 2014. Internal fixation or partial/total hip replacement. The length of stay and cost of hospitalization were compared between patients with VTE and those without using a Student t-test. A logistic regression model was performed to evaluate the trends in VTE rates, and a multivariable linear regression model was performed to evaluate inpatient hospital costs. The overall rates of DVT and PE were 0.3% and 0.53%, respectively. VTE was associated with an increased length of stay (9 days vs. 5 days) and increased inpatient cost ($103,860.83 vs. $51,576.00). The rate of DVT over the study period decreased, whereas the rate of PE increased. Each episode of VTE after hip fracture is a significant source of additional inpatient cost. Patients who sustain a VTE have approximately twice the length of stay and total inpatient cost compared with those who do not. The rates of DVT after hip fracture surgery are decreasing, whereas the rates of PE are increasing. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Primary total hip arthroplasty (THA) procedures continue to increase. On the basis of data from 2000 to 2014, the frequency of THA in the U.S. is projected to grow to 635,000 procedures per year by 20301. The majority of implants from these procedures are expected to last >20 years. A study of 94,292 total hip replacements from the Finnish Arthroplasty Registry noted a survivorship of 58% at 25 years2. THA complications (especially periprosthetic joint infection [PJI] and dislocation), as well as perioperative management to optimize short stays and outpatient THA while minimizing perioperative complications, continue to draw heavy attention. Implant Design and Related Outcomes In a study evaluating 2016 data from the American Joint Replacement Registry (AJRR) compared with other national registries, the authors found that cementless stem fixation combined with the use of ceramic and 36-mm heads was the current preference in the U.S., while other registries indicated that cemented implants and metal and 32-mm heads were most commonly used3. Cemented Versus Cementless Implants There is evidence that cemented implants outperform cementless counterparts in elderly patients when early complication rates are compared. On the basis of the recent Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) annual report, Tanzer et al. reported that, among patients >75 years of age who underwent THA, those treated with the best-performing cementless femoral stems had more early revisions (<30 days postoperatively) compared with those treated with the best-performing cemented implants4. These early revisions were mainly attributable to the risk of revision for fracture or loosening. This difference disappeared after 90 days following surgery4. Bearing Surfaces Metal-on-Polyethylene (MoP) Studies show better long-term survival with a metal-on-highly-cross-linked-polyethylene (HXLPE) articulation compared with metal-on-conventional, non-cross-linked polyethylene (CPE) in younger patients5-7. In a retrospective review of 101 hips in 84 patients ≤50 years of age, with a duration of follow-up of 15 to 20 years, cobalt-chromium (CoCr)-on-CPE showed a high rate of wear-related revision (13 of 101, 12.9%)5. In contrast, the authors of another report noted excellent 15-year survivorship and functional outcome with no wear-related revision in a cohort of 82 patients (89 hips) ≤50 years of age with CoCr-on-HXLPE6. An observational study from the AOANJRR showed that hips in which XLPE was used (199,131 procedures) had a significantly lower revision rate at 16 years following THA for osteoarthritis compared with hips in which CPE was used (41,171 procedures), regardless of the head material7. Ceramic-on-Ceramic (CoC) or Ceramic-on-Polyethylene (CoP) Clicking or squeaking continues to be present in a small percentage of patients who undergo THA with CoC components. In 1 report, audible noise was present in 6.4% of hips (48 of 749) following THA with use of fourth-generation alumina CoC bearings, although no patient underwent revision for clicking or squeaking8. The selection of CoP recently surpassed MoP as the most popular bearing surface used in THA in the U.S.9. Metal-on-Metal (MoM) A study from Korea demonstrated an acceptable rate of aseptic loosening (cup, 10.5%; stem, 6.1%) in a cohort of 114 hips treated with THA using 28-mm MoM components; the average follow-up was 20 years (range, 17 to 23 years)10. Nonetheless, the use of an MoM articulation continues to decline secondary to persistent concerns for metal debris-induced adverse local tissue reactions. Surface Treatment The authors of a prospective multicenter study reported that, at the 5-year follow-up, titanium alloy (Ti6Al4V) acetabular shells with a porous titanium coating (PTC) had a higher percentage of gaps/radiolucency compared with plasma-sprayed (PS) acetabular shells from the same manufacturer (23% versus 5%). Patients in the PTC group had more patient-reported pain, although none underwent revision for loosening11. Short Versus Standard Stems In a randomized double-blinded study, persistent mid-thigh pain was much more prevalent among patients with a short Collum Femoris Preserving (CFP) stem (LINK) (19%) compared with a full-profile wedge-tapered Alloclassic Zweymüller stem (Zimmer) (7%) at medium-term follow-up. Both cohorts, however, had a high percentage of varus malalignment (14% and 16%, respectively), and the results may not be generalizable to other cementless designs12. The association between periprosthetic femoral fracture and length/geometry of cementless implants was also studied. In a cohort study of 5,090 consecutive, direct-anterior primary THAs performed at a single institution, the incidence of periprosthetic fracture using femoral components with 4 variations in length and geometry was evaluated13. All stems were of a single-taper wedge design from the same manufacturer, with 1 of 4 configurations: full-length, standard profile; full-length, reduced distal profile; short-length, standard profile; and short-length, reduced distal profile. There was a trend toward a higher risk of periprosthetic fracture in the short-length-with-standard-profile group13. It is unclear whether the same trend would hold using other surgical approaches. Head Size In a study using data from the Nordic Arthroplasty Register Association database and including 186,231 patients who underwent MoP THA with use of a 28, 32, or 36-mm head, the authors found that the risk of dislocation was reduced with the use of 32 versus 28-mm heads, although the overall revision risk remained similar. Surprisingly, transitioning from 32 to 36-mm heads was associated with a higher risk of revision for all causes, including the risk of dislocation14. It appeared that 32-mm heads would be the optimal choice for MoP THA. Dual-Mobility Constructs Modular dual-mobility constructs employ a CoCr articular surface liner that locks into an outer shell of titanium. A systematic review of mid-term studies of dual-mobility constructs supports their efficacy in reducing the incidence of dislocation after both primary and revision THA15. The wear rate for contemporary dual-mobility constructs using an HXLPE design showed substantially larger magnitudes of initial head penetration and wear than those reported for HXLPE in fixed-bearing couples (twice the rate)16. It approaches a steady state after 2 years, making it comparable with traditional fixed bearings; future studies should address the long-term outcomes16. A propensity score-matched study showed that patients with a dual-mobility construct had a lower risk of revision due to dislocation, although there was no difference in the overall risk of revision between the dual-mobility construct group and the MoP/CoP group. The authors speculated that selection bias may have been present, as the dual-mobility construct group also showed a higher risk of revision due to infection17. Patient Factors in Relation to Outcomes Medical Comorbidities Dialysis dependence was demonstrated to be an independent risk factor for 30-day adverse events, intensive care unit (ICU) care, longer length of stay, and rehabilitation needs in patients undergoing total joint arthroplasty (TJA)18. Patients with hepatitis C who received interferon or direct antiviral agents prior to THA appeared to have fewer postoperative complications, especially PJI19. Dorr Type In a matched comparative study, a higher incidence of femoral stem-related complications (mainly periprosthetic femoral fractures) was observed when using double-tapered wedge stems in Dorr type-A compared with type-B femora20. A study correlating proximal femoral morphology and leg length after THA showed that patients with a Dorr type-A femur and a high femoral cortical index (FCI, defined as the ratio of cortical width minus endosteal width to the cortical width at a level 100 mm below the tip of the lesser trochanter on an anteroposterior radiograph of the hip) were at increased risk of leg lengthening while patients with a Dorr type-C femur and a low FCI had an increased probability of shortening21. Body Mass Index (BMI) Several studies showed a higher risk of complications (up to 3 times) among THA patients classified as morbidly obese compared with normal controls22-24. In particular, researchers in the U.K. reported on, to our knowledge, the largest longitudinal cohort study to date analyzing the influence of BMI on THA outcomes (>410,000 patients)25. Patients who were morbidly obese (BMI of 40 to 60 kg/m2) had the highest probability of revision at 10 years (twice that of the underweight group), while 90-day mortality was significantly higher for the underweight group compared with those with normal BMI. Milder obesity (BMI of 25 to 40 kg/m2) seemed to have a protective effect against mortality25. In another study, patients classified as super obese (BMI of ≥45 kg/m2) had a greater risk of reoperation and readmission and greater 90-day costs compared with the nonobese cohort, but they had comparable quality-of-life improvements26. Patients classified as morbidly obese who underwent bariatric surgery prior to TJA showed a reduced comorbidity burden at the time of TJA, with reduced post-TJA complications; however, the risk of revision was not reduced27. While obesity seems to be a major negative predictor of adverse outcomes, some argue that THA is still cost-effective for morbidly obese and super obese groups and recommend against a cutoff threshold to avoid unnecessary loss of health-care access28. Preoperative Opioid Use Opioid use within 3 months preceding THA was an independent predictor of early revision, while obesity and anxiety/depression were also shown to predict early failure of treatment29. Significantly higher 30-day readmission and revision rates were observed among THA/TKA (total knee arthroplasty) patients with a history of long-term preoperative opioid use30. In another study, patients who used opioids preoperatively tended to have significantly lower patient-reported outcome scores and longer hospital stays, and were more likely to be discharged to a rehabilitation facility31. Tobacco Use In a recent study, smokers had a significantly higher risk of deep infection and reoperation after revision THA compared with nonsmokers, and the risk was higher than for primary THA32. The authors of a systematic review and meta-analysis found that former tobacco users had a significantly lower risk of wound complications and PJI compared with current smokers. Smoking cessation counseling prior to total joint arthroplasty is strongly advocated33. A history of smoking was also recently tied to increased risk of nerve injury in patients undergoing THA34. Surgical Approach The optimal surgical approach in primary THA remains controversial. A systematic review and meta-analysis of prospective studies showed less pain and better reported function through 90 days postoperatively for the direct anterior approach compared with the posterior approach35. However, when comparing early revision rates (<5 years from index primary surgery), the direct anterior approach was associated with a significantly higher rate of early revision due to femoral loosening compared with the posterior approach, while the posterior approach demonstrated a higher incidence of early revision due to instability36. A Dutch joint-registry study showed small improvements in the 3-month postoperative patient-reported outcome measure (PROM) for the direct anterior and posterolateral approaches compared with the direct lateral and anterolateral approaches37. Regardless of the different approaches, there are minimal differences in gait mechanics at early or late follow-up38. The long-term prognosis of lateral femoral cutaneous nerve (LFCN) neuropathy was also investigated. One study found that approximately 11% of patients had persistent LFCN neuropathic symptoms even at 6 to 8 years after direct anterior THA, and the most common presentation was numbness (37%). This, however, did not affect hip functional scores39. Complications There is substantial variation in reported THA complication rates among national databases and joint registries. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) tends to show the lowest rate of complications40. Medical Complications A study of 10-year Hospital Episode Statistics data from the U.K. including 540,623 THAs showed that postoperative medical complications decreased year-after-year despite a steady rise in the average Charlson Comorbidity Index score. The only 2 exceptions were lower respiratory tract infection and renal failure, which continued to rise41. Venous Thromboembolism (VTE) and Anticoagulation A systematic review found that industry-funded studies assessing thromboprophylaxis reported fewer patients with pulmonary embolism (PE), major bleeding, and mortality compared with nonfunded studies42. A cross-sectional study in 5 countries found that the rate of in-hospital VTE after hip arthroplasty was 0.16% in Canada, 1.41% in France, 0.84% in New Zealand, 0.66% in the U.S. (California), and 0.37% in Switzerland, while the benchmark was 0.58%. French data showed a higher rate, potentially because of the systematic use of ultrasound, which could result in the over-detection of deep venous thrombosis (DVT) but not PE43. A retrospective analysis of the NSQIP data set from 2008 to 2016 demonstrated that the risk of DVT was not associated with obesity in patients undergoing THA. The risk of PE, however, was found to be elevated in THA patients whose BMI was ≥35 kg/m2. The authors concluded that, since current pharmacologic anticoagulation regimens can reduce the DVT rate but have not been demonstrated to affect the rate of PE or death, the data do not support increased DVT anticoagulation in THA patients who are obese but without other VTE risk factors44. Dislocation Spinopelvic pathology dominated the literature on THA dislocation, with important research focused on spine-pelvis-hip radiographs in the sagittal plane and the related functional safe zone45-52. It has been proposed that the spinopelvic relationship be categorized according to 4 groups, as assessed at the preoperative evaluation (1A: normal alignment, normal mobility; 1B: normal alignment, stiff spine; 2A: flatback deformity, normal spine; 2B: flatback deformity, stiff spine). Special attention should be paid to the 2B population, for whom surgeons may consider using a dual-mobility construct with targeted 30° of anteversion relative to the functional pelvic plane (based on standing, rather than supine, anteroposterior pelvic radiography)45. A modified classification system was recently proposed on the basis of supine anteroposterior pelvic, standing anteroposterior pelvic, and sitting and standing lateral spinopelvic radiographs46. The classification system adds a hyperlordosis spinal alignment category (pelvic incidence-lumbar lordosis [PI-LL] mismatch of <–10°) and suggests a new risk assessment tool incorporating sagittal spinal alignment (coded as a number) and spine mobility/stiffness (coded as a letter) to use in revision THA. This new assessment tool was validated in a group of 222 patients who underwent revision hip replacement for recurrent instability. Results for 111 patients who were evaluated using the new spinal function assessment were compared with a matched group of 111 patients who were not evaluated using the system. The dislocation rate was 3% among patients who had the new presurgical assessment compared with 16% for those who did not46. Patients undergoing THA with a history of lumbar spinal fusion (LSF) had a >100% increased risk of dislocation compared with those who had LSF 5 years after THA53. Another study found that fusion to the sacrum as well as multiple levels of lumbar involvement dramatically increased the risk of dislocation in primary THA54. Although there was no increased perioperative spike of dislocation in patients undergoing LSF following an otherwise stable THA, 1 study demonstrated that this population had a sustained elevated risk of dislocation (0.7% per year) compared with those without LSF (0.4% risk per year)55. PJI The past decade saw tremendous effort and focus on preventing PJI in patients undergoing TJA. Current unadjusted 1-year and 5-year risks of PJI following THA were found to be 0.69% and 1.09%, respectively. After adjustment, however, there was no detectable decline in the risk of PJI over time56. Once PJI is confirmed, the 1-year weighted mortality rate was noted to be 4.22%, and 5-year mortality, 21.12%, highlighting the devastating consequence of PJI57. A PJI consortium (International Consensus on Orthopedic Infections) recently published a guideline for comprehensive hip and knee PJI diagnosis, prevention, and treatment58-65. With the new evidence-based and validated PJI criteria in 2018, PJI diagnosis now consists of a scoring system for minor criteria in both preoperative and intraoperative diagnosis66. One recent study found that there is no difference in treatment success as defined by the Delphi criteria between patients meeting minor-only criteria and those meeting a major criterion of PJI diagnosis67. Another PJI scoring model assigns relative weights to the various risk factors for PJI following TJA. A previous open surgical procedure, drug abuse, a revision procedure, and human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) were deemed the most influential factors68. A positive association between postoperative urinary tract infection and PJI after THA or TKA was established in a population-based, retrospective cohort study of 113,061 patients (≥66 years old). No association was found between acute postoperative urinary retention and PJI69. Debate continues regarding the merits of 1-stage versus 2-stage revision for PJI. In a recent Danish study, the authors reported an encouraging 91% infection-free survival rate at a minimum of 2 years of follow-up when using 1-stage cementless revision in the treatment of patients with chronic periprosthetic hip joint infection70. In another study, about 30% of revisions had an increase in the vancomycin minimum inhibitory concentration (MIC) between 2 stages, raising concerns about the potential for the emergence of resistant organisms between the stages of a 2-stage revision71. Postoperative Urinary Retention Risk factors for postoperative urinary retention have been defined, including an age of >60 years, intraoperative fluid administration of >1,350 mL, and intraoperative of an of risk factors related to postoperative urinary retention are and should be Although the percentage probability of periprosthetic femoral fracture using cementless stems was demonstrated to be only at 10 years, this dramatically increased to at years after primary another study the incidence of periprosthetic femoral fracture in stems found that the incidence of periprosthetic femoral fracture continued to increase after the decade and the incidence of aseptic loosening in the decade A study using data from the national found that the annual incidence of periprosthetic femoral fracture in primary THAs increased from of to of the of to In the report, type-C 4 more than and they were more commonly in cemented The incidence of with MoP is and an average of 5 years to metal the ratio have been shown to be higher in MoP (range, or compared with MoM (range, to Another study a level of and a ratio of to be a cutoff threshold for important MoP The levels of and to decline by and 3 months after potential in the femoral nerve was observed in 17 of patients who underwent the direct anterior approach in THA when were against the anterior of the although this was The authors of another recent study of the anterior in a relative safe to the to avoid In a recent retrospective cohort study using the A data was found to be associated with significantly lower rates of dislocation and aseptic revision of the acetabular following primary The authors when their results because of potential by In a double-blinded study in the U.K. that patients undergoing THA or the use of with an and to show a in the rate of surgical infection Current and The past decade has a rise in the incidence of both outpatient and THA, according to a recent comparative and have been for or to be while also patient supports a trend toward better postoperative outcomes when hip replacement is performed by While the majority of primary THAs are performed at surgeons are the majority of these A more relationship was by a New data set of of the was associated with a 2 to increase in the risk of complications, mortality, and revision relative to while hospital was associated with a increase in complications and a 4 to increase in The opioid has has more attention in recent years. regarding opioid after joint replacement surgery show that to of patients continue opioid use even at 1 year have been to reduce opioid without of A study indicated that fewer compared with 90 was associated with a in opioid and decreased opioid without pain scores and patient-reported In a retrospective review of patients who underwent THA and TKA reported a history of those reported and including respiratory and In this study, no patient with a who was an adverse It was also found that, for the patients with a who were or no differences could be found in the rate of Use is now an of the THA to reduce loss and the risk of by including the American Association of and Surgeons and the American of Orthopaedic Surgeons state that no of or time of administration have been shown to A recent randomized study did that multiple postoperative of reduced loss compared with a single preoperative The of 1 preoperative of 2 by 3 postoperative of of loss in Smoking A study from the demonstrated that level of 8 within 1 of TJA could significantly rates of smokers It also to of patients who reported as continued smoking and as more than after surgery among those who and A from demonstrated that the administration of could to for among patients undergoing THA, by a in postoperative pain scores of was also in reducing opioid and The of use in patients with undergoing THA or TKA was recently in a retrospective study of 2 of patients in the group and in the patients who received were not found to have a significantly higher infection rate than to the that PJI is an this study have been with the of with a a mainly a spinal using significantly the length of of patients undergoing THA by 1 Postoperative Current evidence that the postoperative of and levels following THA in patients with a normal preoperative level is the should be by risk factors and Preoperative and levels of and 4 have been as below which should consider postoperative and It has been that consider the use of the in for THA including of patients with THA with a had significantly higher than those without a and among the THA with a was greater for those The of The a of recently published studies related to the system that received a higher of In to in this 4 other with a higher of to hip replacement are to this review after the standard with a about to in an evidence-based in this treatment and risk of or after total hip a cohort study from national Danish Joint This to the knowledge, the largest study using the Danish databases to address the association between perioperative treatment and postoperative 30-day PE, and from all among patients who underwent THA. A total of patients were the study from to among received perioperative and did After use was not found to significantly increase the risk of PE, or The authors were to the of using on patients with previous and other in this of on outcomes after primary and revision total hip at the a cohort study patients who underwent primary or revision THA from through A using 32 factors found in the medical including 17 and of was used to the study population as index of of to and of With to in-hospital complications, differences were found only for wound complications and the and with patients had a significantly higher risk of mortality ratio of dislocation, wound and reoperation within 90 days and 1 year after primary THA. The authors did not a association of with aseptic periprosthetic or prior bariatric surgery outcomes following total joint arthroplasty in the morbidly A This meta-analysis studies from to 2018, with a total of patients who underwent THA or underwent bariatric surgery prior to TJA and the patients with obesity as the group. The study found that bariatric surgery prior to TJA was associated with reduced risks of medical complications, length of stay, and The risks of wound infection or and the long-term risks of dislocation, periprosthetic and revision were not the THA and TKA bariatric surgery was associated with a in the risk of PJI after but not after THA. of of and on in the after total hip the randomized The and in is a Danish study the and of 4 regimens or after THA. The was 1 surgery and 6 for for a total of 4 of the on the postoperative and patients were in the The authors found that significantly reduced compared with in the after The surgical approach versus for the study cohort was not which have the postoperative for

We assessed the risk and time trends of venous thromboembolism (VTE) including pulmonary embolism (PE) and deep venous thrombosis (DVT) in new granulomatosis with polyangiitis (GPA) cases compared to the general population. Using a population-level database from the entire province of British Columbia, Canada, we conducted a matched cohort study of all patients with incident GPA with up to ten age-, sex-, and entry time-matched individuals randomly selected from the general population. We compared incidence rates of VTE, PE, and DVT between the two groups, and calculated hazard ratios (HR), adjusting for relevant confounders. Among 549 individuals with incident GPA (57.6% female, mean age 55.4 years), the incidence rates for VTE, PE, and DVT were 7.22, 2.73, and 6.32 per 1,000 person-years, respectively; the corresponding rates were 1.36, 0.74, and 0.81 per 1,000 person-years among the 5,490 non-GPA individuals. Compared with the non-GPA cohort, the fully adjusted HRs among GPA patients were 2.90 (95% CI, 1.10–7.64), 4.70 (95% CI, 1.74–12.69), and 1.66 (95% CI, 0.52–5.27) for VTE, PE, and DVT, respectively. The risks of VTE, PE, and DVT were highest during the first year after GPA diagnosis with HR (95% CI) of 11.04 (1.37–88.72), 26.94 (4.56–159.24), and 2.68 (0.23–31.21), respectively. GPA patients are at significantly increased risk of PE, but not DVT. Monitoring for these complications is particularly warranted in this patient population, especially early after diagnosis.

MP64-14 OUTPATIENT CHEMOPROPHYLAXIS AND RATE OF DEEP VENOUS THROMBOSIS FOLLOWING RADICAL CYSTECTOMY

Reduction mammaplasty is one of the most common plastic surgery procedures performed. No study has evaluated whether geriatric patients are at greater risk for developing postoperative complications relative to nongeriatric patients. The American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database was reviewed for reduction mammaplasty procedures from 2005 to 2017. Hypothesis testing for demographics, comorbidities, and postoperative complications between geriatric and nongeriatric patients was performed. Statistically significant differences were then evaluated with multivariate logistic regression analysis. A total of 25,909 reduction mammaplasties were collected by NSQIP from 2005 to 2017, with 1897 patients older than 64 years (8% of all cases). The average age for geriatric breast reduction patients was 69 years versus 41.5 years for nongeriatric patients. Rates of comorbidities including diabetes, smoking status, dyspnea status, and hypertension medication were statistically different between the groups. Rates of deep venous thrombosis (DVT) and pulmonary embolism (PE) were significantly higher in geriatric versus nongeriatric patients, respectively (0.32 vs 0.06, P < 0.001 and 0.37 vs 0.09, P < 0.001). Multivariate analysis demonstrated geriatric patients had a 4.2 and 3.9 times higher risk of developing a DVT and PE than nongeriatric patients (C.I. 1.5-11.6, P = 0.006 and C.I. 1.6-9.8, P = 0.004). This study represents the largest evaluation of geriatric reduction mammaplasties in the United States. Although rare, geriatric age confers a 4 times increased risk for developing DVT and PE relative to nongeriatric patients all while adjusting for preoperative risk factors in reduction mammaplasty. Plastic surgeons should consider counseling their geriatric patients regarding these increased risks.

More on: venous thromboembolism and mortality after hip fracture: the ESCORTE study

To compare the rate of venous thromboembolism (VTE) in surgical inpatients with pharmacological thromboprophylaxis and additional graduated compression stockings (GCSs) versus pharmacological thromboprophylaxis alone. Surgical inpatients have elevated VTE risk; recent studies cast doubt on whether GCS confers additional protection against VTE, compared with pharmacological thromboprophylaxis alone. The review followed "Preferred Reporting Items for Systematic Reviews and Meta-analyses" guidelines using a registered protocol (CRD42017062655). The MEDLINE and Embase databases were searched up to November 2022. Randomized trials reporting VTE rate after surgical procedures, utilizing pharmacological thromboprophylaxis, with or without GCS, were included. The rates of deep venous thrombosis (DVT), pulmonary embolism, and VTE-related mortality were pooled through fixed and random effects. In a head-to-head meta-analysis, the risk of DVT for GCS and pharmacological thromboprophylaxis was 0.85 (95% CI: 0.54-1.36) versus for pharmacological thromboprophylaxis alone (2 studies, 70 events, 2653 participants). The risk of DVT in pooled trial arms for GCS and pharmacological thromboprophylaxis was 0.54 (95% CI: 0.23-1.25) versus pharmacological thromboprophylaxis alone (33 trial arms, 1228 events, 14,108 participants). The risk of pulmonary embolism for GCS and pharmacological prophylaxis versus pharmacological prophylaxis alone was 0.71 (95% CI: 0.0-30.0) (27 trial arms, 32 events, 11,472 participants). There were no between-group differences in VTE-related mortality (27 trial arms, 3 events, 12,982 participants). Evidence from head-to-head meta-analysis and pooled trial arms demonstrates no additional benefit for GCS in preventing VTE and VTE-related mortality. GCS confer a risk of skin complications and an economic burden; current evidence does not support their use for surgical inpatients.