Venous thromboembolism in patients hospitalized for knee joint replacement surgery

Abstract

Patients undergoing knee joint replacement (KJR) are at high risk of postoperative venous thromboembolism (VTE), but data on the time trends of VTE rate in this population are sparse. In this analysis of the German nationwide inpatient sample, we included all hospitalizations for elective primary KJR in Germany 2005–2016. Overall, 1,804,496 hospitalized patients with elective primary KJR (65.1% women, 70.0 years [IQR 63.0–76.0]) were included in the analysis. During hospitalization, VTE was documented in 23,297 (1.3%) patients. Total numbers of primary KJR increased from 129,832 in 2005 to 167,881 in 2016 (β-(slope)-estimate 1,978 [95% CI 1,951 to 2,004], P < 0.001). In-hospital VTE decreased from 2,429 (1.9% of all hospitalizations for KJR) to 1,548 (0.9%) cases (β-estimate − 0.77 [95% CI − 0.81 to − 0.72], P < 0.001), and in-hospital death rate from 0.14% (184 deaths) to 0.09% (146 deaths) (β-estimate − 0.44 deaths per year [95% CI − 0.59 to − 0.30], P < 0.001). Infections during hospitalization were associated with a higher VTE risk. VTE events were independently associated with in-hospital death (OR 20.86 [95% CI 18.78–23.15], P < 0.001). Annual number of KJR performed in Germany increased by almost 30% between 2005 and 2016. In parallel, in-hospital VTE rates decreased from 1.9 to 0.9%. Perioperative infections were associated with higher risk for VTE. Patients who developed VTE had a 21-fold increased risk of in-hospital death.

Recommendations from the ICM-VTE: General

“…In a large nationwide study on hip replacements including 1,885,839 patients from 2005 - 2016 in Germany, Keller at al., reported that the number of VTE events increased with age (β 0.33 per age decade [95% CI 0.30 - 0.35]) 67 . A second study including 1,804,496 hospitalized patients who had elective primary knee joint replacement demonstrated that VTE risk was age-dependent (β 0.14 [95% CI 0.12 - 0.15], per age decade) 68 . In accordance with these findings, in the Danish Knee Arthroplasty Registry, Pedersen et al, identified 37,223 primary knee arthroplasties performed from 1997 - 2007 in patients who received pharmacological thromboprophylaxis 77 .…”

Risk Factors for Pulmonary Embolism in Patients with Paralysis and Deep Venous Thrombosis

“…Other studies reported that without VTE prophylaxis, approximately 50-75% of stroke patients with hemiplegia or paralysis develop DVT [1,5,6]. Thus, VTE is a common complication in spinal cord injury and stroke with resulting paresis [3,5,[7][8][9][10][11]36]. Among traumatic injuries, traumatic spine injuries of the spinal cord and/or the cauda equina are connected with the highest VTE risk [36].…”

“…Notably, in patients with stroke or paralysis, PE occurs in approximately one-fifth of these patients [5], and PE events are affected by aggravated outcomes with high morbidity and mortality [5,7,9,32]. Therefore, since the incidence of DVT is high in patients with paralysis [3,5] the risk for PE increases with DVT rate and PE events are accompanied by a high risk of death in the short-term [4,9,11,20], it is of major interest to identify factors associated with development of the life-threatening complication of acute PE.…”

“…Paralysis is categorized as a moderate to strong risk factor for the development of venous thromboembolism (VTE) [1][2][3][4][5][6][7][8][9].It has been estimated that the incidence of deep venous thrombosis in paralysis and stroke patients exceeds even the incidence of deep venous thrombosis in patients with general surgeries, and might be similar to the high rates occurring after hip and knee joint arthroplasty [1,3,[5][6][7]10,11].…”

“…Since the incidence of VTE, comprising deep venous thrombosis and PE, is high in patients with paralysis [3,5] and the VTE sub-entity PE, especially, is accompanied by a high risk of an adverse in-hospital course [4,9,11,20] it is of outstanding interest to identify factors that result in or are associated with the development of the life-threatening complication of an acute PE.…”