Wound Problems following Hip Arthroplasty before and after the Introduction of a Direct Thrombin Inhibitor for Thromboprophylaxis

Abstract

In the United Kingdom, national guidelines have stated that patients undergoing elective hip surgery are at increased risk for venous thromboembolic events (VTE) following surgery and have recommended thromboprophylaxis for 28-35 days (1, 2). Studies of direct thrombin inhibitors have hitherto concentrated on major bleeding. We prospectively assessed wound discharge in patients who underwent hip arthroplasty and who received oral dabigatran postoperatively between March 2010 and April 2010 (n=56). We compared these results to a retrospective matched group of patients who underwent similar operations six months earlier, at which time all patients were given subcutaneous dalteparin routinely postoperatively until discharge, and then discharged home on 150 mg aspirin daily for 6 weeks (n=67). Wound discharge after 5 days was significantly higher in the patients taking dabigatran (32% dabigatran n=18, 10% dalteparin n=17, p=0.003) and our rate of delayed discharges due to wound discharge significantly increased from 7% in the dalteparin group (n=5) to 27% for dabigatran (n=15, p=0.004). Patients who received dabigatran were more than five times as likely to return to theatre with a wound complication compared with those who received dalteparin (7% dabigatran n=4, vs. 1% dalteparin n=1), but this was not statistically significant (p=0.18). We now administer dalteparin until the wound is dry and then start dabigatran. Our study demonstrates the need for further clinical studies regarding wound discharge and direct thrombin inhibitors.

Do We Know All About Prevention of Venous Thromboembolism After Major Orthopedic Surgery?

“…при этом у пациентов с указанным фактором риска ВТэо развивались чаще после Тэп коленного (7,96%), а не тазобед-ренного сустава (0%) [22]. В другом исследовании с участием небольшого количества пациентов была изучена безопасность дабигатрана, которую оценивали по количеству пациентов, у которых сохранялось раневое отде-ляемое на 5-е сутки после операции и позже [23]. В исследуемую группу вошли 56 пациентов, ко-торые после операции получали дабигатран пе-рорально в течение всего периода тромбопро-филактики (6 нед.).…”

“…кроме того, пациенты, получавшие дабигатран, чаще обращались за медицинской помощью по поводу осложнений в области хи-рургического вмешательства. после получения результатов исследования авторы изменили протокол тромбопрофилактики: дабигатрана этексилат пациентам стали давать только после достижения полного гемостаза (при сухой ране), назначая до этого момента нМг (дальтепарин) [23]. p. Mommsen с соавторами, оценивая объем кровопотери у 198 пациентов (111 пациентов в исследуемой группе и 87 пациентов в группе контроля), не выявили существенных различий по данному показателю между дабигатраном и эноксапарином [24].…”

Thromboprophylaxis with dabigatran leads to an increased incidence of wound leakage and an increased length of stay after total joint replacement

“…Tinzaparin has been linked with haematoma formation and sciatic nerve palsy following THR, 19 and rivaroxaban has been associated with a significant increase in the number of patients returning to theatre within 30 days of TJR. 6 Dabigatran has already been shown, in one small study, to increase wound leakage compared to LMWH, 20 and the authors of this study suggested the inpatient use of LMWH followed by dabigatran as an outpatient. A meta-analysis of different VTE regimens in 2012 suggested that the use of rivaroxaban was associated with an increased bleeding tendency compared with enoxaparin, but that for dabigatran and enoxaparin the rates of bleeding were broadly similar.…”

New oral pharmacotherapeutic agents for venous thromboprophylaxis after total hip arthroplasty

“…A pooled analysis of phase Ⅲ studies of orthopedic thromboprophylaxis (excluding RE-NOVATE Ⅱ) found no differences in surgical site bleeding or wound infection although smaller independent investigations have since suggested a possible increased risk of post-operative wound complications with dabigatran compared to LMWH [55,56] . No incidence of spinal hematoma was ob-served in patients receiving both dabigatran and neuraxial anesthesia during three of four phase Ⅲ studies (excluded RE-NOVATE Ⅱ) [57] .…”