Medicinske komplikationer efter hofte- og knæalloplastik (THA and KA) med fokus på trombosekomplikationer Alma B. Pedersen
Outline Introduction to epidemiology of THA and KA Epidemiology of medical complications: Dødelighed Venous thromboembolism Thrombosis vs. bleeding Thromboprophylaxis Conclusion RADS anbefalinger
Introduction De seneste årtier har der været en stigning i antallet af THA og KA I hele verden. Med baggrund i det stigende antal ældre i befolkningen kan der i de kommende år forventes en fortsat stigning i antallet af operationer Ældre patienter har ofte én eller flere konkurrerende sygdomme og øget risiko for komplikationer
Incidence rate of THA and KA in Denmark Dansk Hofte- o g Knæalloplastik Register
Risk of death following primary total hip replacement: comparison with general population 0-30 days : THA vs. Controls = adjusted RR 1.4 (95% CI 1.2-1.7) No increased risk beyond 30 days J Bone Joint Surg [Br] 2011: 93-B: 172-77
Risk of death following primary total hip replacement: comparison with general population J Bone Joint Surg [Br] 2011: 93-B: 172-77
Venous thromboembolism Venous thromboembolism (VTE), including deep venous thrombosis and pulmonary embolism, are serious complications in patients undergoing THA/KA since more than 25% of patients died within 1 year of VTE. The risk of symptomatic VTE within 3 months of THA/KA has been reported to be between 1.3% and 3.2% in patients with thromboprophylaxis.
Results VTE The overall risk of VTE within 90 days after primary THA was 1.0% (686 / 67469) The corresponding risk after primary KA was 1.2% (441/37223) Only 15% of the THA patients and 33% of the KA patients were diagnosed with their VTE episode in an orthopedic department, whereas the rest were admitted to other departments, mainly departments of internal medicine.
Time from primary THA to hospitalization with VTE within 90 days Median follow-up time of 22 days
Time from primary KA to hospitalization with VTE within 90 days Median follow-up time of 15 days
Results - Risk factors for VTE in THA and KA Increased risk in THA and KA: High level of comorbidity Cardiovascular diseases Previous DVT or PE (adjusted RR = 8.06 and 5.30) Increased risk in THA: Cementless arthroplasty Hybrid arthroplasty General anaesthesia
Risk of VTE following primary THA: comparison with general population
Risk of VTE following primary THA: comparison with general population Study population primary THAs in Denmark from 1995 to 2010 (n=85,965). comparison cohort without THR from the general population (n=257,895). Matched on gender and age. Outcome: one year risk of hospitalization with VTE
Adjusted RR Risk of VTE following primary THA: comparison with general population 20 18 16 14 12 10 8 6 4 2 0 The risk of VTE was elevated irrespective of the gender, age or level of comorbidity 0-90 days 91-365 days Days after THA surgery VTE DVT PE
Risk of thromboembolism and clinically relevant bleeding 90 days following THA and TKA Outcome THA N=51,002 n (%) TKA N=32,754 n (%) Thromboembolism 1173 (2.3) 750 (2.3) -Myocardial infarction 286 (0.6) 126 (0.4) -Ischemic stroke 272 (0.5) 161 (0.5) -Venous tromboembolism 638 (1.3) 476 (1.5) Clinically relevant bleeding 306 (0.6) 177 (0.5) -Intracranial bleeding 19 (0.04) 11 (0.03) -Gastrointestinal bleeding 168 (0.3) 111 (0.3) -Other bleeding 120 (0.2) 57 (0.2) All-cause mortality 381 (0.8) 180 (0.7)
Risk of thromboembolism and clinically relevant bleeding 90 days following THA and TKA 4 Time trend in the risk of thromboembolism and clinically relevant bleeding 3,5 % 3 2,5 2 1,5 1 Thromboembolism Clinically relevant bleeding lower CI thromboembolism upper CI thromboembolism lower CI bleeding upper CI bleeding 0,5 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Dansk Hofte- Knæalloplastik Register
Risk of thromboembolism and clinically relevant bleeding 90 days following THA and TKA 1,8 Time trend in the risk of thromboembolism and clinically relevant bleeding % 1,6 1,4 1,2 1 0,8 0,6 0,4 0,2 Myocardial infarction Stroke without bleeding Venous thromboembolism Stroke with bleeding Gastrointestinal bleeding 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Dansk Hofte- Knæalloplastik Register
Length of thromboprophylaxis Extended thrombopropylaxis for four weeks following THA is recommended in current guidelines Current practice: Length of thromboprohylaxis after THA (days) in Denmark:
Conclusions THA and KA are in general effective and safe procedures with a high success rate. Medical complications, in particular thromboembolism, remain a concern despite surgical, pharmacological and diagnostic advances. VTE: Approximately 1% within 90 days of THA/KA THA surgery is associated with an increased risk of VTE up to at least one year after surgery compared to the general population, although the absolute risk is small. The risk of postoperative VTE have not been reduced since the mid 1990 s AMI and Stroke: 1% within 90 days of THA/TKA The risk of postoperative AMI and stroke has been the same/decreasing during the last 15 years in DK Clinically relevant bleeding: 0.5% within 90 days of THA/TKA The risk of bleeding has been the same during the last 15 years in DK Continued attention to better pre-operative risk assessment and individualized preventive measures combined with early detection of complications appear warranted
Rådet for Anvendelse af Dyr Sygehusmedicin (RADS) RADS blev etableret af Danske Regioner i oktober 2009 Behandlingsvejledning for terapiområdet tromboseprofylakse til ortopædkirurgiske patienter: hoftealloplastik, knæalloplastik og hoftebrud RADS skal sikre en ensartet anvendelse af tromboseprofylakse på tværs af regioner og sygehuse Bygger på nationale og internationale guidelines
Følgende lægemidler er medtaget i behandlingsvejledningen Gruppe 1- parenterale Xa-hæmmere Dalteparin (Fragmin) Enoxaparin (LMWH) Tinzaparin (Innohep) Fondaparinux (Arixtra) 2- orale Xa-hæmmere Apixaban (Eliquis) Rivaroxaban (Xarelto) 3- orale trombin-hæmmere Dabigatran Etexilat (Pradaxa)
Behandlingskriterier, marts 2013 Elektive knæalloplastik 10-14 dage Elektive hoftealloplastik 28-35 dage Til patienter hvor oral behandling ud fra en samlet vurdering bør foretrækkes: Apixaban (Eliquis) Rivaroxaban (Xarelto) Apixaban (Eliquis) Rivaroxaban (Xarelto) Til patienter hvor parenteral behandling ud fra en samlet vurdering bør foretrækkes: Dalteparin (Fragmin) Enoxaparin (LMWH) Tinzaparin (Innohep) Fondaparinux (Arixtra) Dalteparin (Fragmin) Enoxaparin (LMWH) Tinzaparin (Innohep) Fondaparinux (Arixtra) Hofte fraktur Standard 7-10 dage hvor oral og parenteral behandling er ligestillet. Bagefter skal man tage vurdering, og hvis patienten ikke er mobiliseret eller har andre konkurrerende sygdomme som risiko faktor, skal den behandles som medicinsk patient, dvs. langtidsprofylakse skal iværksættes.
Tak for jeres opmærksomhed Korrespondance: Abp@dce.au.dk