Top

Journal of Orthopaedic Surgery and Research

Published in:

Open Access 01-12-2015 | Research article

Bridging therapy for oral anticoagulation increases the risk for bleeding-related complications in total joint arthroplasty

Authors: Martijn Haighton, Diederik H R Kempen, Nienke Wolterbeek, Louis N. Marting, Martijn van Dijk, Remmelt M R Veen

Published in: Journal of Orthopaedic Surgery and Research | Issue 1/2015

Abstract

Background

Patients scheduled for elective surgery with a high risk of thromboembolism require anticoagulation bridging therapy perioperatively. The purpose of this study was to assess the risk of thromboembolic events and bleeding-related complications after total hip and knee arthroplasty in patients requiring bridging therapy for anticoagulants.

Methods

A retrospective cohort study of all patients with primary total hip or total knee replacement in a 4-year period was performed. Outcome measures were blood loss, thromboembolic and bleeding-related complications and hospital stay.

Results

Bridged patients had more blood loss and higher complication rates than the control group. Most complications were bleeding-related, and there were no thromboembolic events. Seven of the 14 (50 %) total hip patients bridged with unfractioned heparin required reoperation (three patients with ischial neuropraxia due to hematoma). There were two bleeding-related deaths in total hip patients bridged with low-molecular-weight heparin. Mean hospital stay was significantly longer in unfractioned heparin bridging.

Conclusion

In this study, there was a significant increase in bleeding-related complications in total joint replacement with bridging therapy compared to prophylaxis. This risk was highest in patients with total hip arthroplasty. There were no thromboembolic events in bridged patients.

Jaff MR. Chronically anticoagulated patients who need surgery: can low-molecular-weight heparins really be used to “bridge” patients instead of intravenous unfractionated heparin? Catheter Cardiovasc Interv. 2009;74:S17–21.CrossRefPubMed

Spyropoulos AC, Turpie AGG, Dunn AS, Spandorfer J, Douketis J, Jacobson A, et al. Clinical outcomes with unfractionated heparin or low-molecular-weight heparin as bridging therapy in patients on long-term oral anticoagulants: the REGIMEN registry. J Thromb Haemost. 2006;4:1246–52.CrossRefPubMed

Spyropoulos AC, Turpie AGG, Dunn AS, Kaatz S, Douketis J, Jacobson A, et al. Perioperative bridging therapy with unfractionated heparin or low-molecular-weight heparin in patients with mechanical prosthetic heart valves on long-term oral anticoagulants (from the REGIMEN Registry). Am J Cardiol. 2008;102:883–9.CrossRefPubMed

Douketis J, Johnson JA, Turpie AG, AGG. low-molecular-weight heparin as bridging anticoagulation during interruption of warfarin. Assessment of a standardized periprocedural anticoagulation regimen. Arch lntern Med. 2004;164:1319–26.CrossRef

Kovacs MJ, Kearon C, Rodger M, Anderson DR, Turpie AGG, Bates SM, et al. Single-arm study of bridging therapy with low-molecular-weight heparin for patients at risk of arterial embolism who require temporary interruption of Warfarin. Circulation. 2004;110:1658–63.CrossRefPubMed

Haas SB, Barrack RL, Westrich G, Lachiewicz PF. Venous thromboembolic disease after total hip and knee arthroplasty. J Bone Joint Surg Am. 2008;90-A:2764–80.

Douketis J, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, et al. Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest physicians. Evidence-based clinical practice guidelines. Chest. 2012;141(2 Suppl):e326s–50.PubMedCentralPubMed

Cardiovascular Disease Educational and Research Trust, Cyprus Cardiovascular Disease Educational and Research Trust, European Venous Forum; International Surgical Thrombosis Forum, International Union of Angiology, Union Internationale de Phlébologie. International consensus statement. Int Angiol. 2006;25(2):101–61.

Jacobs JJ, Mont MA, Bozic KJ, Della Valle CJ, Goodman SB, Lewis CG, et al. American Academy of Orthopaedic Surgeons clinical practice guideline on: preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Bone Joint Surg Am. 2012;94(8):746–7.PubMedCentralCrossRefPubMed

10.

Heyers TM. Management of venous thromboembolism. Past, present and future. Arch lntern Med. 2003;1063:759–68.CrossRef

11.

Hull RD, Graham F, Pineo GF, Stein PD, et al. Extended out-of-hospital low-molecular-weight heparin prophylaxis against deep venous thrombosis in patients after elective hip arthroplasty: a systematic review. Ann Intern Med. 2001;135:858–69.CrossRefPubMed

12.

Bloomfield MR, Patterson RW, Froimson ML. Complications of anticoagulation for thromboembolism in early postoperative total joint arthroplasty. Am J Orthop (Belle Mead NJ). 2011;40(8):E148–51.

13.

Patterson BM, Marchand R, Ranawat C. Complications of heparin therapy after total joint arthroplasty. J Bone Joint Surg Am. 1989;71(8):1130–4.PubMed

14.

McDougall CJ, Gray HS, Simpson PM, Whitehouse SL, Crawford RW, Donnelly WJ. Complications related to therapeutic anticoagulation in total hip arthroplasty. J Arthroplasty. 2013;28(1):187–92.CrossRefPubMed

15.

Lawton RL, Morrey BF. The use of heparin in patients in whom a pulmonary embolism is suspected after total hip arthroplasty. J Bone Joint Surg Am. 1999;81(8):1063–72.PubMed

16.

Kalairajah Y, Simpson D, Cossey AJ, Verrall GM, Spriggins AJ. Blood loss after total knee replacement: effects of computer-assisted surgery. J Bone Joint Surg Br. 2005;87(111):1480–2.CrossRefPubMed

17.

Spyropoulos AC, Jenkins P, Bornikova L. A disease management protocol for outpatient perioperative bridge therapy with enoxaparin in patients requiring temporary interruption of long-term oral anticoagulation. Pharmacotherapy. 2004;24:649–58.CrossRefPubMed

18.

Ferreira L, Dos L, Tornos P, Nicolau I, Permanyer-Miralda G, Soler-Soler J. Experience with enoxaparin in patients with mechanical heart valves who must withhold acenocoumarol. Heart. 2003;89:527–30.PubMedCentralCrossRefPubMed

19.

Halbritter KM, Wawer A, Beyer J, Oettler W, Schellong SM. Bridging anticoagulation for patients on long-term vitamin-K-antagonists. A prospective 1 year registry of 311 episodes. J Thromb Haemost. 2005;3:2823–5.CrossRefPubMed

20.

Baudo F, de Cataldo F, Mostarda G, Ghirarduzzi A, Molinatti M, Pengo V, et al. Management of patients on long-term oral anticoagulant therapy undergoing elective surgery: survey of the clinical practice in the Italian anticoagulation clinics. Intern Emerg Med. 2007;2:280–4.CrossRefPubMed

21.

Hammerstingl C, Tripp C, Schmidt H, von der Recke G, Omran H. Periprocedural bridging therapy with low-molecular-weight heparin in chronically anticoagulated patients with prosthetic mechanical heart valves: experience in 116 patients from the prospective BRAVE registry. J Heart Valve Dis. 2007;16:285–92.PubMed

22.

Jaffer AK, Ahmed M, Brotman DJ, Bragg L, Seshadri N, Qadeer MA, et al. Low-molecular-weight-heparins as periprocedural anticoagulation for patients on long-term warfarin therapy: a standardized bridging therapy protocol. J Thromb Thrombolysis. 2005;20:11–6.CrossRefPubMed

23.

Constans M, Santamaria A, Mateo J, Pujol N, Souto JC, Fontcuberta J. Low-molecular-weight heparin as bridging therapy during interruption of oral anticoagulation in patients undergoing colonoscopy or gastroscopy. Int J CIin Pract. 2007;61:212–7.CrossRef

24.

Simpson PM, Brew CJ, Whitehouse SL, Crawford RW, Donnelly BJ. Complications of perioperative warfarin therapy in total knee arthroplasty. J Arthroplasty. 2014;29(2):320–4.CrossRefPubMed

25.

Thorburn CW, Morgan JJ, Sanan MX, Chang VP. Long-term results of tricuspid valve replacement and the problem of the prosthetic valve thrombosis. Am J Cardiol. 1983;51:1128–32.CrossRefPubMed

26.

Cannegieter SC, Rosendaal FR, Briet E. Thromboembolic and bleeding complications in patients with mechanical heart valve prostheses. Circulation. 1994;89:635–41.CrossRefPubMed

27.

Vongpatanasin W, Hillis D, Lange RA. Prosthetic heart valves. N Engl J Med. 1996;335:407–16.CrossRefPubMed

28.

Prandoni P, Villalta S, Bagatella P, et al. The clinical course of DVT. Prospective long term follow up of 528 symptomatic patients. Haematologica. 1997;82:423–8.PubMed

29.

Eijgenraam P, Ten Cate H, Ten Cate-Hoek AJ. Practice of bridging anticoagulation: guideline adherence and risk factors for bleeding. Neth J Med. 2014;72(3):157–64.PubMed

Title: Bridging therapy for oral anticoagulation increases the risk for bleeding-related complications in total joint arthroplasty
Authors: Martijn Haighton
Diederik H R Kempen
Nienke Wolterbeek
Louis N. Marting
Martijn van Dijk
Remmelt M R Veen
Publication date: 01-12-2015
Publisher: BioMed Central
Published in: Journal of Orthopaedic Surgery and Research / Issue 1/2015
Electronic ISSN: 1749-799X
DOI: https://doi.org/10.1186/s13018-015-0285-6

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Bridging therapy for oral anticoagulation increases the risk for bleeding-related complications in total joint arthroplasty

Abstract

Background

Methods

Results

Conclusion

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 1/2015

Induction of granulation tissue for the secretion of growth factors and the promotion of bone defect repair

Comparison of clinical and radiologic treatment outcomes of Kienböck’s disease

A novel, cryopreserved, viable osteochondral allograft designed to augment marrow stimulation for articular cartilage repair

Meta-analysis for dorsally displaced distal radius fracture fixation: volar locking plate versus percutaneous Kirschner wires

The effects of a dynamic patellar realignment brace on disease determinants for patellofemoral instability in the upright weight-bearing condition

Anterior-only stabilization using cage versus plating with bone autograft for the treatment of type II/IIA Hangman’s fracture combined with intervertebral disc injury