George Komnos, Theofilos Karachalios, Eugénia Cruz, Farideh Najafi, Neusha Hollingworth, Javad Parvizi.
Response/Recommendation: It is generally known that the severe acute respiratory syndrome-related coronavirus (SARS-CoV [COVID – 19]) infection predisposes individuals to a higher risk of thromboembolism. However, there is not sufficient data to suggest that a previous COVID – 19 infection increases the risk of venous thromboembolism (VTE) after an orthopaedic procedure. Thus, the VTE prophylaxis of patients with prior COVID – 19 does not need to be altered.
Strength of Recommendation: Limited.
Rationale: It has been demonstrated that COVID – 19 infection can result in coagulopathy and thromboembolic disease1 with a high risk of VTE2. This can be explained by the association between COVID – 19 and inflammation, increased clot firmness and decreased clot formation time3. Similar to the effects of COVID – 192,4,5 orthopaedic injuries cause a hyperinflammatory and hypercoagulable response, increasing VTE risk. The additive effects of these factors can amplify inflammatory response to the traumatic insult and pose an even greater VTE risk, while lowering survival rates6. Because of the latter concern and the potential for increased risk for mortality, some studies have proposed that elective surgical intervention be delayed in patients with active COVID – 19 infection7,8. On the other hand, there is also some data to suggest that patients who had a delay in receiving their total joint arthroplasty due to COVID – 19 protocols may be at risk of VTE9.
Appropriate thromboprophylaxis is essential to prevent venous thrombotic complications associated with orthopaedic procedures, whether surgeries are elective (as hip and knee arthroplasties) or due to trauma10–13. Extended prophylaxis (for up to 45 days) can be considered for patients with elevated risk of VTE (e.g., immobility, presence of comorbidities such as active cancer or prior VTE)14-16. It is also important to include the assessment of bleeding risk in this decision. However, anticoagulant choice, dosage, and the duration in patients undergoing orthopaedic procedures who have previously been infected with COVID – 19 are not yet well studied. Several factors, such as the severity and length of the COVID – 19 infection, and the comorbidities of the individual seem to lead to a high heterogeneity of VTE presentation among this population17. The issue of VTE prophylaxis for patients with COVID – 19 infection was discussed by the International Consensus Group (ICM) and in their published guidelines of July 2020, the recommendation was to administer some form of VTE prophylaxis for this patient group undergoing orthopedic procedures18.
In a recent study by Perazzo et al,19. 16 patients with fracture of proximal femur who also had COVID – 19 infection were evaluated. The first seven patients received a single daily dose of low-molecular-weight heparin (LMWH), among whom four patients died of cardiovascular complications (four deaths). In the following nine patients with COVID – 19 and proximal femoral fracture, the dose of LMWH was doubled. There was only one death in that group. None of the patients died of VTE related complications and the sample size was so small that no conclusive deductions could be drawn from the study.
In a review paper, some investigators attempted to evaluate the potential implications of commonly prescribed medications in orthopaedic surgery for COVID – 19 patients, including VTE prophylaxis20. In one letter, some authorities recommended that injectable VTE prophylaxis be used in lieu of oral anticoagulant21. The authors felt that patients with COVID – 19 infection exhibited high variability in prothrombin time and international normalized ratio (INR) due to the issues with vitamin K metabolism in patients with acute viral infection. They also felt that patients with COVID – 19 receiving other oral anticoagulants may be exposed to under/over treatment caused by significant pharmacological interferences. Similar recommendations were made by other authorities in a follow-up publication22. There is some data to suggest that aspirin may be useful in preventing critical illness associated with COVID – 1923 and it is also stipulated that oral anticoagulants may help decrease the hyperinflammatory effects of COVID – 19 in general24.
In conclusion, and based on current data, there is no need to change the VTE prophylaxis of patients with prior COVID – 19 undergoing orthopedic procedures. The decision to choose one agent versus other should rely on the risk-benefit ratio for these patients like others.
References:
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2. Fogarty H, Townsend L, Ni Cheallaigh C, et al. COVID19 coagulopathy in Caucasian patients. Br J Haematol. 2020;189(6):1044-1049. doi:10.1111/bjh.16749
3. The Procoagulant Effect of COVID-19 on the Thrombotic Risk of Patients with Hip Fractures Due to Enhanced Clot Strength and Fibrinolysis Shutdown – PubMed. Accessed September 30, 2021. https://pubmed.ncbi.nlm.nih.gov/34362178/
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21. Testa S, Paoletti O, Giorgi-Pierfranceschi M, Pan A. Switch from oral anticoagulants to parenteral heparin in SARS-CoV-2 hospitalized patients. Intern Emerg Med. 2020;15(5):751-753. doi:10.1007/s11739-020-02331-1
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