Francisco Bengoa, Henrik Malchau, Juan José Pellegrini, Agustín Vial, Søren Overgaard.

Response/Recommendation: Patients undergoing total knee arthroplasty (TKA) have a higher venous thromboembolism (VTE) risk than total hips arthroplasty (THA) patients. In addition, VTE tends to present earlier in TKA patients. There is no evidence for different risk profiles among patients undergoing THA or TKA. Also, there is also no clarity on whether it is necessary to stratify TKA differently than THA patients, or how to do it.

Strength of recommendation: Limited.

Rationale: Modern surgical protocols and the use of thromboprophylaxis have reduced deep venous thrombosis (DVT) rates in both TKA and THA patients, but not pulmonary embolism (PE) rates^1–4. However, differences in VTE risk persist between both procedures.

DVT rates after THA have varied over time. Dua et al., and Shahi et al., both studied the United States National Inpatient Sample (NIS), and found in-hospital VTE rates of 0.59% after THA (DVT 0.4% and PE 0.23%)^1,2. DVT rates decreased from 2002 to 2011, from 0.55 to 0.24%, but PE rates did not¹. However, other studies have found conflicting results. Using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database and analyzing 30-day VTE rates, Warren et al., found no changes between 2008 and 2016, and Grosso et al., found no changes between 2006 and 2016^5,6. Pedersen et al., found a slight increase in 90-day hospitalizations for venous thromboembolism between 1995 and 2006⁷. Lieberman et al., evaluated 21 randomized controlled trials of several VTE prophylaxis strategies in low-risk patients undergoing THA⁴. They found a PE rate of 0.21%, which did not change between 1997 and 2013, and suggested that PE even in a healthy population are not completely avoidable.

Similar findings regarding temporal changes in VTE rates have been found in TKA patients. However, thromboembolic risk continues to be higher than after THA^1,2,5,8. Using the NIS, Dua et al., found a decrease in in-hospital DVT rates after TKA between 2001 to 2011, from 0.86 to 0.45%¹. Shahi et al., found higher in-hospital incidence rates of VTE of 0.62% in patients undergoing TKA, versus 0.40% in THA, and similarly, DVT rates decreased during the studied period, but PE rates did not². Using the NSQIP database, Sarpong et al., and Warren et al., found that 30-day VTE rates decreased between 2006 and 2016^5,8. Sarpong et al., found a 0.87% 30-day DVT rate in 221,764 patients that decreased from 1.5% in the 2006 to 2009 period to 0.79% in the 2014 to 2016 period. Warren et al., found a 30-day VTE rate of 1.4% that decreased from 3% in 2008 to 1.4% in 2016⁵. However, mortality and PE rates did not experience changes. Other studies have also failed to find a decrease in PE rates after TKA. Cote et al., performed a meta-analysis including 18 studies with 27,073 patients that underwent TKA between 1996 and 2010⁹. They found a symptomatic PE rate of 0.37%, that did not change over time.

Patients undergoing revision THA appear to have a higher risk of VTE than primary THA. Studies using the NSQIP and NIS databases show VTE, DVT, and PE rates in revision THA of 0.6 to 1.34%, 0.7 to 1.06%, and 0.3 to 0.4%, respectively^2,10,11. Interestingly, revision TKA confers a VTE risk somewhat similar to that of a primary TKA. Shahi et al., found higher in-hospital VTE rates in revision TKA compared to primary TKA, using the NIS database². Thirty-day rates of VTE, DVT, and PE, using the NSQIP and NIS databases, were 1.16 to 2%, 0.88 to 0.9%, 0.34 to 0.4%, respectively^2,5,10. Contrarily, Boylan et al., found a higher VTE risk within 30 days after primary TKA (i.e., 2.24%, DVT 1.61%, and PE 0.82%) than revision TKA (i.e., 1.84%, DVT, 1.41%, and PE 0.52%), using the New York Statewide Planning and Research Cooperative System database¹². Different from primary arthroplasties, VTE rates have not decreased over the last decades for revision surgeries.

Patients undergoing TKA not only have a higher risk of VTE, but they get a VTE earlier after surgery than THA patients. Pedersen et al., found a median time to VTE that was 20 to 22 days for patients undergoing THA, and 15 days for those who underwent TKA, using Danish registers^7,13. Gill et al., found a median time for DVT of 16 days in THA and 14 days in TKA in a cohort of more than 13,000 patients in the United Kingdom¹⁴. Using United States data, several studies have confirmed these findings^11,15–17. Bohl et al., found patients undergoing TKA had an earlier time to PE (day 3 vs. 5 in THA) and DVT (day 5 vs. 13)¹⁵. Johnson et al., reviewed 341,601 primary THA and TKA patients¹⁶. Of patients who had a PE, those who underwent a TKA had a PE earlier than those who underwent a THA (81,7% during the first 10 days, versus 58.8%). Interestingly, Courtney et al., found no differences in time to DVT (12.9 s vs. 14.8 days) or to PE (9.2 vs. 8.6 days) in patients undergoing primary or revision THA¹¹.

Most studies have investigated risk factors in both THA and TKA patients. As such, TKA has been identified as a risk factor, but most other risk factors appear to be similar between patients undergoing both procedures^11,18–26. Zhang et al., performed a meta-analysis of ten risk factors for VTE after TKA and THA²⁷. They included 14 retrospective case-control or prospective cohort studies. They found that three risk factors were the most associated with VTE: history of VTE (odds ratio [OR] > 10.6), varicose veins (OR > 2.7), and congestive heart failure (OR 2.03). Zhang et al., performed a systematic review on level I and II evidence on VTE risk factors after TJA between 2003 and 2013²⁸. They included 54 studies. They found that several risk factors were associated with increased VTE risk. Increasing age, body mass index over 30, bilateral surgery, female patients, and surgery duration longer than two hours were identified as risk factors for both TKA and THA patients. Patients undergoing TKA surgery had a higher VTE risk, compared to those undergoing THA. In TKA patients, cemented fixation was identified as a risk factor and early mobilization was identified as a protective factor. In THA patients, a previous VTE conferred a higher risk for VTE.

Regional variability may also play a role in VTE rate differences. Several reports suggest lower VTE rates in Asian patients, both in THA and TKA^{18–21,29–34}. Lee et al., performed a meta-analysis of the incidence of VTE in Asian patients undergoing TKA who did not use thromboprophylaxis³². They included 18 studies, totaling 1,838 patients. The rate of symptomatic PE was low (0.01%), similar between countries, and consistent in time. Seven studies reported symptomatic DVT, which was 1.9%. As such, the Asia-Pacific Venous Thromboembolism Consensus has agreed that the risk of VTE is lower in patients of Asian ethnicity³³. These results differ markedly from those coming from other parts of the world. European studies have shown VTE, DVT, and PE rates of 0.79 to1.3%, 0.35 to 0.46%, and 0.35 to 0.57% for THA and 1.5%, 0.3 to 0.51%, and 0.51 to 1.47% for TKA, respectively^{13,14,22,35,36}. Januel et al., performed a comparative study between patients who underwent THA in Canada, Switzerland, New Zealand, California, and France³⁷. They found that VTE rates varied between countries (0.16 to 1.41%) during hospital stays. Length of stay and ultrasound screening strategies explained only partially these differences, but other factors like completeness of registration and validity of diagnoses may play a role.

References:

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