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Aspirin provides adequate VTE prophylaxis for patients undergoing hip preservation surgery, including periacetabular osteotomy

Aspirin provides adequate VTE prophylaxis for patients undergoing hip preservation surgery,... Journal of Hip Preservation Surgery Vol. 5, No. 2, pp. 125–130 doi: 10.1093/jhps/hny010 Advance Access Publication 5 April 2018 Research article Aspirin provides adequate VTE prophylaxis for patients undergoing hip preservation surgery, including periacetabular osteotomy 1,2 1 1 1 Ibrahim Azboy *, Michael M. Kheir , Ronald Huang and Javad Parvizi Rothman Institute at Thomas, Jefferson University Hospital, Sheridan Building, Suite 1000 125 South 9th Street, Philadelphia, PA 19107, USA and Department of Orthopaedics and Traumatology, Istanbul Medipol University, Kavacık Mah. Ekinciler Cad. No.19 Kavacık Kavs¸ag - Beykoz 34810, Turkey, Istanbul *Correspondence to: I. Azboy. E-mail: ibrahimazboy@gmail.com Submitted 5 July 2017; revised version accepted 16 March 2018 ABSTRACT There are no clear guidelines regarding optimal venous thromboembolism (VTE) prophylaxis for patients under- going hip preservation surgery (HPS), in particular pelvic osteotomy, which is considered to be a major orthopaedic procedure. The aim of this study was to determine the efficacy of aspirin for VTE prophylaxis in a large cohort of patients undergoing femoroacetabular osteoplasty (FAO) and periacetabular osteotomy (PAO). This was a retro- spective study of prospectively collected data on patients undergoing HPS. A total of 603 patients (643 cases) underwent FAO and 80 patients (87 cases) underwent PAO between 2003 and 2016. The mean age of patients was 34.3 years (range 14.3–68.1 years). The type of VTE prophylaxis administered changed over time with earlier patients receiving warfarin (44 cases), followed by aspirin at 325 mg twice daily (448 cases), and most recently aspirin 81 mg twice daily (238 cases). The complications of symptomatic pulmonary embolism (PE), deep venous thrombosis (DVT) and major bleeding events within 90 days of surgery were documented. There were zero patients that developed major bleeding events or required evacuation of a hematoma. One patient who underwent FAO and received aspirin 325 mg, developed post-operative symptomatic DVT. One patient who underwent PAO and received aspirin 325 mg developed DVT and PE. This study demonstrates that the incidence of VTE following joint preservation procedure is acceptably low. Administration of aspirin to patients undergoing FAO or PAO appears to be adequate in reducing the risk of VTE. Only two patients in this cohort developed VTE following HPS. healthy and active, which places them at a lower risk for INTRODUCTION morbidity post-operatively, including VTE, compared with Venous thromboembolism (VTE) is considered a serious more elderly patients requiring joint arthroplasty [9]. In complication after any surgical procedures including hip addition, recent improvements in perioperative protocols preservation surgery (HPS) [1–6]. The optimal VTE pro- including spinal anesthesia and early mobilization may phylaxis regimen after HPS, including femoroacetabular have reduced the rate of VTE regardless of prophylaxis osteoplasty (FAO) and periacetabular osteotomy (PAO), method [10, 11]. Thus, an evidence-based recommenda- remains unclear [2–5]. VTE prophylaxis recommendations tion for VTE prophylaxis regimen after HPS is warranted are mainly derived from total joint arthroplasty (TJA) liter- alongside these recent advances. ature [6, 7]. These recommendations have evolved in The initial AAOS guideline in 2007 has recommended recent years. The American College of Chest Physicians ASA 325 mg bis in die (BID) following TJA [12]. (ACCP) and the American Academy of Orthopaedic However, studies originating from both trauma and arthro- Surgeons (AAOS) accept aspirin (ASA) as an effective plasty literature have demonstrated that lower doses of modality for VTE prophylaxis following TJA [1, 8]. ASA areas effective for VTE prevention as higher doses Patients undergoing HPS surgery are relatively young, V C The Author(s) 2018. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by- nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/125/4962128 by Ed 'DeepDyve' Gillespie user on 20 June 2018 126  I. Azboy et al. Table I. Demographic data of patients Table II. The distribution of venous thromboembo- lism prophylaxis agent in the cohort FAO group PAO group FAO group PAO group Total Number of patient (cases) 603 (643) 80 (87) (n¼ 643) (n¼ 87) Gender male/female 307/296 70/10 325-mg Aspirin 415 33 448 Age (years) 34.4 (15.3–68.1) 31.3 (14.3–47.8) 81-mg Aspirin 207 31 238 Body mass index (kg/m ) 26.9 (17.4–41.2) 25.9 (18.9–42.6) Warfarin 21 23 44 Charlson comorbity Total 643 87 730 index (%) FAO, femoroacetabular osteoplasty; PAO, periacetabular osteotomy. 0 89.4 91.2 1 11.4 8.8 received warfarin (44 cases), followed by aspirin at 325 mg twice daily (448 cases), and most recently aspirin 81 mg 3 0.2 twice daily (238 cases; see Figs 1 and 2). Cases were not FAO, femoroacetabular osteoplasty; PAO: periacetabular osteotomy. routinely screened for post-operative VTE. The presence of symptomatic pulmonary embolism (PE), deep venous of ASA [13]. As the gastrointestinal (GI) adverse effects of thrombosis (DVT) and major bleeding events within aspirin is dose dependent, the administration of low dose 90 days of surgery were documented. aspirin is believed to positively impact the rate of GI- The indication for FAO was the presence of a cam or related issues [14, 15]. pincer deformity, labral tear and the presence of persistent In the early years of our study, we utilized warfarin as hip pain in the absence of advanced arthritis. The indication the main modality for VTE prevention following joint for PAO was hip pain in the presence of acetabular dysplasia arthroplasty and HPS. With the publication of the AAOS and the absence of advanced osteoarthritis. All patients guidelines for prevention of VTE [8, 12] and later by the received conservative management including non-steroidal ACCP [1], endorsing aspirin as an effective chemoprophy- anti-inflammatory drugs and/or physical therapy or intra- lactic drug for VTE following joint arthroplasty, we felt articular injections prior to surgical intervention. The surgi- that aspirin could be administered to patients undergoing cal technique for FAO consisted of a mini-open muscle-spar- HPS, including those undergoing PAO. Thus, in 2005 we ing anterior approach using the modified Smith–Petersen made a switch from the use of warfarin to aspirin. Initially approach [16]. Bony impingementatthe femoralhead–neck higher doses of aspirin were being administered to patients junction and/or acetabular rim were addressed, and the lab- undergoing HPS. The dose of aspirin was later lowered. ral and chondral lesions were treated accordingly [9]. Currently there are no VTE prophylaxis recommenda- Surgical exposure for PAO was achieved using the tions for patients undergoing HPS. In this study, we aimed muscle-sparing modified Smith–Petersen approach, with a to evaluate the outcomes of different VTE prophylaxis regi- 10- to 12-cm anterior incision and dissection through mens in a large cohort of patients undergoing HPS, includ- the plane of the tensor fascia lata and sartorius [17]. The ing FAO and PAO. medial aspect of the ilium was exposed, extending to the sciatic notch, and the psoas was retracted medially for MATERIALS AND METHODS exposure of the pubis. The three osteotomies, starting at This retrospective study consists of 645 patients (675 cases) the anteromedial ischium and progressing to the pubis undergoing FAO and 88 patients (96 cases) undergoing and ilium, were performed indirectly under fluoroscopy PAO between 2003 and 2016. All cases were performed by to mobilize and reorient the acetabulum. Fully threaded a single surgeon. Patients were followed prospectively to 4.5 mm cortical screws were used for fixation of the osteot- identify 90-day post-operative complications. The VTE pro- omy fragment. The posterior column was left intact, allow- phylaxis data were available for 603 FAO patients (643 ing for immediate rehabilitation without casting or a brace. cases) and 80 PAO patients (87 cases) (Table I). The mean As thromboprophylaxis, patients received warfarin, ASA age of this cohort was 34.3 years (range 14.3–68.1 years). 325 mg BID or ASA 81 mg BID for 4 weeks post-opera- The type of VTE prophylaxis administered was based tively, beginning on the day of surgery along with compres- on surgeon preference and mirrored VTE prophylaxis pro- sion mechanical prophylaxis for the length of the hospital tocols in TJA at our institution (Table II). Earlier patients stay. The average hospital stay was 1.6 days (range Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/125/4962128 by Ed 'DeepDyve' Gillespie user on 20 June 2018 Aspirin provides adequate VTE prophylaxis after hip preservation surgery  127 Fig. 1. VTE: Venous thromboembolism, FAO: Femoroacetabular osteoplasty Fig. 2. VTE: Venous thromboembolism, PAO: Periacetabular osteotomy 1–5 days). The post-operative weightbearing protocol for extremity ultrasound and chest CT/VQ scans were only FAO patients was 6 weeks of partial weight bearing. Post- performed in cases of suspected symptomatic VTE. GI com- operative partial weightbearing with crutches for 6 weeks plications were defined as upper GI bleeding or ulceration was allowed for patients undergoing PAO. All patients confirmed by endoscopy. We used only major bleeding as a were trained to start circumduction exercises at home. clinically relevant complication related to thromboprophy- Patients were instructed to return for their first post-opera- laxis. Major bleeding events included fatal bleeding, bleeding tive visit between weeks 4 and 6. Return to full activity, into a critical organ (e.g. retroperitoneal, intracranial, intra- including high-impact sports was allowed after 3 months ocular, or intraspinal), clinically overt bleeding (e.g. GI) or post-operatively. requiring3 units of blood transfusion after surgery, and Post-operative complications occurring within 90 days bleeding leading to reoperation [1]. Statistical analyses were after surgery were recorded, including symptomatic performed with SPSS 18.0 statistical software (SPSS Inc., DVT and PE, GI complications including bleeding or Chicago, IL, USA). A P values less than 0.05 was considered ulceration, acute superficial or deep infection, and mortality. as statistically significant. Symptomatic DVTs were detected using lower extremity ultrasound and PEs were diagnosed using chest computed RESULTS tomography (CT), or ventilation perfusion (V/Q) scans. The overall incidence of a VTE complication 90 days fol- Patients were not routinely screened for VTE. Lower lowing FAO was one per 643 cases (0.16%). The overall Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/125/4962128 by Ed 'DeepDyve' Gillespie user on 20 June 2018 128  I. Azboy et al. Table III. The overall 90 day post-operative venous thromboembolism following hip preservation surgery Prophylaxis agent Number of cases VTE event (n) VTE rate (%) FAO group (n¼643) 325-mg Aspirin 415 1 81-mg Aspirin 207 0 0.16 Warfarin 21 0 PAO group (n¼87) 325-mg Aspirin 33 1 81-mg Aspirin 31 0 1.1 Warfarin 23 0 HPS cohort (n¼730) 730 2 0.28 VTE, venous thromboembolism; HPS, hip preservation surgery; FAO, femoroacetabular osteoplasty; PAO, periacetabular osteotomy. Table IV. Comparison of venous thromboembolism events between the prophylaxis agents 325-mg Aspirin 81-mg Aspirin Warfarin P value a b c FAO group 1 (415) 0 (207) 0 (21) 0.667 and 0.954 a b c PAO group 1 (33) 0 (31) 0 (23) 0.516 and 0.589 a b c HPS cohort 2 (448) 0 (238) 0 (44) 0.653 and 0.911 The values are given as the number of VTE event, with the number of cases in parentheses. A 325-mg Aspirin versus 81-mg Aspirin. A 325-mg Aspirin versus Warfarin. VTE, venous thromboembolism; HPS, hip preservation surgery; FAO, femoroacetabular osteoplasty; PAO, periacetabular osteotomy. incidence of VTE complication after PAO was one per 87 was positive for acute thrombus of the left posterior tibial cases (1.1%) (Table III). No major bleeding events devel- and peroneal veins. She received intravenous heparin on oped in patient undergoing FAO or PAO. admission and was transitioned to injectable low-molecular There was no difference between ASA 325 mg and ASA weight heparin. The patient was discharged home on enox- 81 mg in regards to the VTE rate after HPS (P¼ 0.653). aparin 80 mg BID for 5 days, and warfarin 10 mg daily. The Also, there was no difference between ASA 325 mg and patient received warfarin for 3 months with resolution of warfarin in regard to VTE rate after HPS (0.911). No dif- symptoms. She was doing well at her two year follow-up ference in VTE rate was observed between ASA 325 mg with no further complications. and ASA 81 mg after FAO (P¼ 0.667). Furthermore, no One 44-year-old male patient had symptomatic DVT difference in VTE rate was observed between ASA 325 mg after an FAO. The patient was discharged on aspirin and ASA 81 mg after PAO (P¼ 0.516) (Table IV). 325 mg BID. He developed pain and swelling in his lower One 42-year-old female patient developed a DVT and extremity. The DVT was diagnosed with lower extremity PE after PAO. The patient was discharged on aspirin ultrasound and the patient was treated with warfarin for 325 mg BID. She developed episodic transient stabbing 3 months with resolution of symptoms and no further pain in the popliteal fossa and intermittent episodes of complications. chest pain, palpitation, diaphoresis and shortness of breath DISCUSSION 5 days post-operatively. Her symptoms progressed, and she was admitted to the emergency room on post-operative HPS is a popular and effective surgical procedure for the day 17. A chest X-ray was obtained which demonstrated a management of young patients with minimal arthritis prominent right pulmonary trunk. A CT scan of the thorax and symptomatic hip pathology [18]. The most effective was obtained which demonstrated a filling defect in the mode of prevention of VTE following HPS remains anterior and superior branches of the right upper lobe pul- unknown with little published on this subject matter [2–5, monary artery, consistent with PE. Ultrasound of the leg 9]. Recommendations for VTE prophylaxis are mainly Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/125/4962128 by Ed 'DeepDyve' Gillespie user on 20 June 2018 Aspirin provides adequate VTE prophylaxis after hip preservation surgery  129 based on the TJA literature [1, 6–8, 12, 13]. This is gastrointestinal problems were not evaluated in this study important as the demographics in the HPS population are and may be better evaluated in a prospective randomized different from that of the TJA population, with patients study. Lastly, a confounding variable in our study is that undergoing HPS more likely to be younger, more active, recent advances in perioperative protocols including the and healthier [9]. use of spinal anesthesia and early mobilization protocols Zaltz et al. analysed the type of prophylaxis and inci- may have reduced the rate of VTE events regardless of the dence of clinically symptomatic VTE after utilizing prophylaxis regimen [10, 11]; this is difficult to account for different methods of prophylaxis for a total of 1067 peria- due to the retrospective nature of the study, however we cetabular osteotomies [2]. They reported an overall inci- still demonstrate a very low event rate of VTE in this pop- dence of VTE to be 0.94%. Polkowski et al. studied the ulation (only two events in this study). frequency of thromboembolic disease in adult patients In conclusion, this study suggests that aspirin is a safe undergoing PAO and receiving aspirin twice daily as well and an effective modality in minimizing the risk of VTE in as mechanical prophylaxis by assessing an ultrasound at patients undergoing HPS including PAO. 1 week post-operatively [3]. They found a 1.3% rate of DVT on routine screening of 136 hips, with a mean patient CONFLICT OF INTEREST STATEMENT age of 30 years (range 18–60 years). They concluded that None declared. routine post-operative screening did not detect any patients with an asymptomatic DVT. Bryan et al. reported a thromboembolic disease rate of 2 out of 75 (2.67%) REFERENCES patients receiving ASA 325 mg twice daily as well as mechanical prophylaxis after undergoing a Bernese PAO 1. Falck-Ytter Y, Francis CW, Johanson NA et al. Prevention of VTE in orthopedic surgery patients: antithrombotic therapy and [11]. Another study by Thawrani et al. reported on 83 prevention of thrombosis: American College of Chest Physicians PAO cases (n¼ 76 patients) in whom no prophylaxis was evidence-based clinical practice guidelines. CHEST 2012; 141: administered and found no cases of symptomatic VTE in e278S–325S. that small cohort [4]. The symptomatic VTE rate in our 2. Zaltz I, Beaule P, Clohisy JC et al. Incidence of deep vein throm- study is 0.16% and 1.1% after FAO and PAO surgery, bosis and pulmonary embolus following periacetabular osteot- respectively, consistent with rates reported previously in omy. J Bone Joint Surg Am 2011; 93: 62–5. the literature. 3. Polkowski GG, Duncan S, Bloemke A et al. Screening for deep Aspirin has been shown to be a safe and effective drug vein thrombosis after periacetabular osteotomy in adult patients: for VTE prophylaxis following TJA, and is supported by is it necessary? Clin Orthop Relat Res 2014; 472: 2500–5. the most recent AAOS and ACCP guidelines [6, 19, 20]. 4. Thawrani D, Sucato D, Podeszwa D, DeLaRocha A. Complications associated with the Bernese periacetabular osteot- In recent studies, aspirin, when compared with more omy for hip dysplasia in adolescents. J Bone Joint Surg Am 2010; potent anticoagulants, was found to reduce the rate of 92: 1707–14. hematoma formation and subsequent wound complica- 5. Tischler EH, Ponzio DY, Diaz-Ledezma C, Parvizi J. Prevention tions, including infection, while providing similar efficacy of venous thromboembolic events following femoroacetabular in prevention of VTE [19–22]. Similarly, in our study, osteoplasty: aspirin is enough for most. Hip Int 2014; 24: 77–80. there was no significant difference in symptomatic VTE 6. Huang RC, Parvizi J, Hozack WJ et al. Aspirin is as effective rates following HPS in patients receiving warfarin, ASA as and safer than Warfarin for patients at higher risk of 325 mg or ASA 81 mg. venous thromboembolism undergoing total joint arthroplasty. This study has several limitations. First, although the J Arthroplasty 2016; 31: 83–6. number of cases are considerable for ASA 325 mg 7. Radzak KN, Wages JJ, Hall KE, Nakasone CK. Rate of Transfusions after total knee arthroplasty in patients receiving (n¼ 448) and ASA 81 mg (n¼ 238), the sample size is lovenox or high-dose aspirin. J Arthroplasty 2016; 1: 2447–51. smaller for those that received warfarin (n¼ 44). 8. Mont MA, Jacobs JJ. AAOS clinical practice guideline: preventing Therefore, this study was underpowered to detect a differ- venous thromboembolic disease in patients undergoing elective ence between VTE rates in patients receiving warfarin hip and knee arthroplasty. J Am Acad Orthop Surg 2011; 19: compared with aspirin. However, to our knowledge this is 777–8. the largest cohort comparing VTE prophylaxis using differ- 9. Cohen SB, Huang R, Ciccotti MG et al. Treatment of femoroace- ent modalities in patients undergoing HPS. Second, a tabular impingement in athletes using a mini-direct anterior higher dose of ASA has been thought to increase the risk approach. Am J Sports Med 2012; 40: 1620–7. of GI complications [15]. However, in our study, no major 10. Atwal NS, Bedi G, Lankester BJ et al. Management of blood loss GI bleeding or ulcer complications were recorded. Minor in periacetabular osteotomy. Hip Int 2008; 18: 95–100. Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/125/4962128 by Ed 'DeepDyve' Gillespie user on 20 June 2018 130  I. Azboy et al. 11. Bryan AJ, Sanders TL, Trousdale RT, Sierra RJ. Intravenous tra- 17. Troelsen A, Elmengaard B, Søballe K. A new minimally invasive nexamic acid decreases allogeneic transfusion requirements in transsartorial approach for periacetabular osteotomy. J Bone Joint Surg Am 2008; 90: 493–8. periacetabular osteotomy. Orthopedics 2016; 39: 44–8. 12. Johanson NA, Lachiewicz PF, Lieberman JR et al. Prevention of 18. Leunig M, Beaule´ PE, Ganz R. The concept of femoroacetabular symptomatic pulmonary embolism in patients undergoing total impingement: current status and future perspectives. Clin Orthop hip or knee arthroplasty. J Am Acad Orthop Surg 2009; 17: Relat Res 2009; 467: 616–22. 183–96. 19. Mostafavi Tabatabaee R, Rasouli MR, Maltenfort MG et al. Cost- 13. Prevention of pulmonary embolism and deep vein thrombosis effective prophylaxis against venous thromboembolism after total with low dose aspirin: pulmonary Embolism Prevention (PEP) joint arthroplasty: warfarin versus aspirin. J Arthroplasty 2015; 30: trial. Lancet 2000; 355: 1295–302. 159–64. 14. de Abajo FJ, Garcia Rodriguez LA. Risk of upper gastrointestinal 20. Ogonda L, Hill J, Doran E et al. Aspirin for thromboprophylaxis after bleeding and perforation associated with low-dose aspirin as primary lower limb arthroplasty: early thromboembolic events and plain and enteric-coated formulations. BMC Clin Pharmacol 90 day mortality in 11, 459 patients. Bone Joint J 2016; 98-B: 341–8. 2001; 1:1. 21. An VV, Phan K, Levy YD, Bruce WJ. Aspirin as thromboprophy- 15. Dutch TIA, Trial Study Group. Van Gjin J, Algra A, Kapelle J laxis in hip and knee arthroplasty: a systematic review and meta- et al. A comparison of two doses of aspirin (30 mg vs. 283 mg a analysis. J Arthroplasty 2016; 31: 2608–16. day) in patients after a transient ischemic attack or minor ische- 22. Huang R, Buckley PS, Scott B et al. Administration of aspirin as a mic stroke. N Engl J Med 1991; 325: 1261–6. prophylaxis agent against venous thromboembolism results in 16. Bender B, Nogler M, Hozack WJ. Direct anterior approach lower incidence of periprosthetic joint infection. J Arthroplasty fortotal hip arthroplasty. Orthop Clin North Am 2009; 40: 321–8. 2015; 30: 39–41. Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/125/4962128 by Ed 'DeepDyve' Gillespie user on 20 June 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Hip Preservation Surgery Oxford University Press

Aspirin provides adequate VTE prophylaxis for patients undergoing hip preservation surgery, including periacetabular osteotomy

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Journal of Hip Preservation Surgery Vol. 5, No. 2, pp. 125–130 doi: 10.1093/jhps/hny010 Advance Access Publication 5 April 2018 Research article Aspirin provides adequate VTE prophylaxis for patients undergoing hip preservation surgery, including periacetabular osteotomy 1,2 1 1 1 Ibrahim Azboy *, Michael M. Kheir , Ronald Huang and Javad Parvizi Rothman Institute at Thomas, Jefferson University Hospital, Sheridan Building, Suite 1000 125 South 9th Street, Philadelphia, PA 19107, USA and Department of Orthopaedics and Traumatology, Istanbul Medipol University, Kavacık Mah. Ekinciler Cad. No.19 Kavacık Kavs¸ag - Beykoz 34810, Turkey, Istanbul *Correspondence to: I. Azboy. E-mail: ibrahimazboy@gmail.com Submitted 5 July 2017; revised version accepted 16 March 2018 ABSTRACT There are no clear guidelines regarding optimal venous thromboembolism (VTE) prophylaxis for patients under- going hip preservation surgery (HPS), in particular pelvic osteotomy, which is considered to be a major orthopaedic procedure. The aim of this study was to determine the efficacy of aspirin for VTE prophylaxis in a large cohort of patients undergoing femoroacetabular osteoplasty (FAO) and periacetabular osteotomy (PAO). This was a retro- spective study of prospectively collected data on patients undergoing HPS. A total of 603 patients (643 cases) underwent FAO and 80 patients (87 cases) underwent PAO between 2003 and 2016. The mean age of patients was 34.3 years (range 14.3–68.1 years). The type of VTE prophylaxis administered changed over time with earlier patients receiving warfarin (44 cases), followed by aspirin at 325 mg twice daily (448 cases), and most recently aspirin 81 mg twice daily (238 cases). The complications of symptomatic pulmonary embolism (PE), deep venous thrombosis (DVT) and major bleeding events within 90 days of surgery were documented. There were zero patients that developed major bleeding events or required evacuation of a hematoma. One patient who underwent FAO and received aspirin 325 mg, developed post-operative symptomatic DVT. One patient who underwent PAO and received aspirin 325 mg developed DVT and PE. This study demonstrates that the incidence of VTE following joint preservation procedure is acceptably low. Administration of aspirin to patients undergoing FAO or PAO appears to be adequate in reducing the risk of VTE. Only two patients in this cohort developed VTE following HPS. healthy and active, which places them at a lower risk for INTRODUCTION morbidity post-operatively, including VTE, compared with Venous thromboembolism (VTE) is considered a serious more elderly patients requiring joint arthroplasty [9]. In complication after any surgical procedures including hip addition, recent improvements in perioperative protocols preservation surgery (HPS) [1–6]. The optimal VTE pro- including spinal anesthesia and early mobilization may phylaxis regimen after HPS, including femoroacetabular have reduced the rate of VTE regardless of prophylaxis osteoplasty (FAO) and periacetabular osteotomy (PAO), method [10, 11]. Thus, an evidence-based recommenda- remains unclear [2–5]. VTE prophylaxis recommendations tion for VTE prophylaxis regimen after HPS is warranted are mainly derived from total joint arthroplasty (TJA) liter- alongside these recent advances. ature [6, 7]. These recommendations have evolved in The initial AAOS guideline in 2007 has recommended recent years. The American College of Chest Physicians ASA 325 mg bis in die (BID) following TJA [12]. (ACCP) and the American Academy of Orthopaedic However, studies originating from both trauma and arthro- Surgeons (AAOS) accept aspirin (ASA) as an effective plasty literature have demonstrated that lower doses of modality for VTE prophylaxis following TJA [1, 8]. ASA areas effective for VTE prevention as higher doses Patients undergoing HPS surgery are relatively young, V C The Author(s) 2018. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by- nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/125/4962128 by Ed 'DeepDyve' Gillespie user on 20 June 2018 126  I. Azboy et al. Table I. Demographic data of patients Table II. The distribution of venous thromboembo- lism prophylaxis agent in the cohort FAO group PAO group FAO group PAO group Total Number of patient (cases) 603 (643) 80 (87) (n¼ 643) (n¼ 87) Gender male/female 307/296 70/10 325-mg Aspirin 415 33 448 Age (years) 34.4 (15.3–68.1) 31.3 (14.3–47.8) 81-mg Aspirin 207 31 238 Body mass index (kg/m ) 26.9 (17.4–41.2) 25.9 (18.9–42.6) Warfarin 21 23 44 Charlson comorbity Total 643 87 730 index (%) FAO, femoroacetabular osteoplasty; PAO, periacetabular osteotomy. 0 89.4 91.2 1 11.4 8.8 received warfarin (44 cases), followed by aspirin at 325 mg twice daily (448 cases), and most recently aspirin 81 mg 3 0.2 twice daily (238 cases; see Figs 1 and 2). Cases were not FAO, femoroacetabular osteoplasty; PAO: periacetabular osteotomy. routinely screened for post-operative VTE. The presence of symptomatic pulmonary embolism (PE), deep venous of ASA [13]. As the gastrointestinal (GI) adverse effects of thrombosis (DVT) and major bleeding events within aspirin is dose dependent, the administration of low dose 90 days of surgery were documented. aspirin is believed to positively impact the rate of GI- The indication for FAO was the presence of a cam or related issues [14, 15]. pincer deformity, labral tear and the presence of persistent In the early years of our study, we utilized warfarin as hip pain in the absence of advanced arthritis. The indication the main modality for VTE prevention following joint for PAO was hip pain in the presence of acetabular dysplasia arthroplasty and HPS. With the publication of the AAOS and the absence of advanced osteoarthritis. All patients guidelines for prevention of VTE [8, 12] and later by the received conservative management including non-steroidal ACCP [1], endorsing aspirin as an effective chemoprophy- anti-inflammatory drugs and/or physical therapy or intra- lactic drug for VTE following joint arthroplasty, we felt articular injections prior to surgical intervention. The surgi- that aspirin could be administered to patients undergoing cal technique for FAO consisted of a mini-open muscle-spar- HPS, including those undergoing PAO. Thus, in 2005 we ing anterior approach using the modified Smith–Petersen made a switch from the use of warfarin to aspirin. Initially approach [16]. Bony impingementatthe femoralhead–neck higher doses of aspirin were being administered to patients junction and/or acetabular rim were addressed, and the lab- undergoing HPS. The dose of aspirin was later lowered. ral and chondral lesions were treated accordingly [9]. Currently there are no VTE prophylaxis recommenda- Surgical exposure for PAO was achieved using the tions for patients undergoing HPS. In this study, we aimed muscle-sparing modified Smith–Petersen approach, with a to evaluate the outcomes of different VTE prophylaxis regi- 10- to 12-cm anterior incision and dissection through mens in a large cohort of patients undergoing HPS, includ- the plane of the tensor fascia lata and sartorius [17]. The ing FAO and PAO. medial aspect of the ilium was exposed, extending to the sciatic notch, and the psoas was retracted medially for MATERIALS AND METHODS exposure of the pubis. The three osteotomies, starting at This retrospective study consists of 645 patients (675 cases) the anteromedial ischium and progressing to the pubis undergoing FAO and 88 patients (96 cases) undergoing and ilium, were performed indirectly under fluoroscopy PAO between 2003 and 2016. All cases were performed by to mobilize and reorient the acetabulum. Fully threaded a single surgeon. Patients were followed prospectively to 4.5 mm cortical screws were used for fixation of the osteot- identify 90-day post-operative complications. The VTE pro- omy fragment. The posterior column was left intact, allow- phylaxis data were available for 603 FAO patients (643 ing for immediate rehabilitation without casting or a brace. cases) and 80 PAO patients (87 cases) (Table I). The mean As thromboprophylaxis, patients received warfarin, ASA age of this cohort was 34.3 years (range 14.3–68.1 years). 325 mg BID or ASA 81 mg BID for 4 weeks post-opera- The type of VTE prophylaxis administered was based tively, beginning on the day of surgery along with compres- on surgeon preference and mirrored VTE prophylaxis pro- sion mechanical prophylaxis for the length of the hospital tocols in TJA at our institution (Table II). Earlier patients stay. The average hospital stay was 1.6 days (range Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/125/4962128 by Ed 'DeepDyve' Gillespie user on 20 June 2018 Aspirin provides adequate VTE prophylaxis after hip preservation surgery  127 Fig. 1. VTE: Venous thromboembolism, FAO: Femoroacetabular osteoplasty Fig. 2. VTE: Venous thromboembolism, PAO: Periacetabular osteotomy 1–5 days). The post-operative weightbearing protocol for extremity ultrasound and chest CT/VQ scans were only FAO patients was 6 weeks of partial weight bearing. Post- performed in cases of suspected symptomatic VTE. GI com- operative partial weightbearing with crutches for 6 weeks plications were defined as upper GI bleeding or ulceration was allowed for patients undergoing PAO. All patients confirmed by endoscopy. We used only major bleeding as a were trained to start circumduction exercises at home. clinically relevant complication related to thromboprophy- Patients were instructed to return for their first post-opera- laxis. Major bleeding events included fatal bleeding, bleeding tive visit between weeks 4 and 6. Return to full activity, into a critical organ (e.g. retroperitoneal, intracranial, intra- including high-impact sports was allowed after 3 months ocular, or intraspinal), clinically overt bleeding (e.g. GI) or post-operatively. requiring3 units of blood transfusion after surgery, and Post-operative complications occurring within 90 days bleeding leading to reoperation [1]. Statistical analyses were after surgery were recorded, including symptomatic performed with SPSS 18.0 statistical software (SPSS Inc., DVT and PE, GI complications including bleeding or Chicago, IL, USA). A P values less than 0.05 was considered ulceration, acute superficial or deep infection, and mortality. as statistically significant. Symptomatic DVTs were detected using lower extremity ultrasound and PEs were diagnosed using chest computed RESULTS tomography (CT), or ventilation perfusion (V/Q) scans. The overall incidence of a VTE complication 90 days fol- Patients were not routinely screened for VTE. Lower lowing FAO was one per 643 cases (0.16%). The overall Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/125/4962128 by Ed 'DeepDyve' Gillespie user on 20 June 2018 128  I. Azboy et al. Table III. The overall 90 day post-operative venous thromboembolism following hip preservation surgery Prophylaxis agent Number of cases VTE event (n) VTE rate (%) FAO group (n¼643) 325-mg Aspirin 415 1 81-mg Aspirin 207 0 0.16 Warfarin 21 0 PAO group (n¼87) 325-mg Aspirin 33 1 81-mg Aspirin 31 0 1.1 Warfarin 23 0 HPS cohort (n¼730) 730 2 0.28 VTE, venous thromboembolism; HPS, hip preservation surgery; FAO, femoroacetabular osteoplasty; PAO, periacetabular osteotomy. Table IV. Comparison of venous thromboembolism events between the prophylaxis agents 325-mg Aspirin 81-mg Aspirin Warfarin P value a b c FAO group 1 (415) 0 (207) 0 (21) 0.667 and 0.954 a b c PAO group 1 (33) 0 (31) 0 (23) 0.516 and 0.589 a b c HPS cohort 2 (448) 0 (238) 0 (44) 0.653 and 0.911 The values are given as the number of VTE event, with the number of cases in parentheses. A 325-mg Aspirin versus 81-mg Aspirin. A 325-mg Aspirin versus Warfarin. VTE, venous thromboembolism; HPS, hip preservation surgery; FAO, femoroacetabular osteoplasty; PAO, periacetabular osteotomy. incidence of VTE complication after PAO was one per 87 was positive for acute thrombus of the left posterior tibial cases (1.1%) (Table III). No major bleeding events devel- and peroneal veins. She received intravenous heparin on oped in patient undergoing FAO or PAO. admission and was transitioned to injectable low-molecular There was no difference between ASA 325 mg and ASA weight heparin. The patient was discharged home on enox- 81 mg in regards to the VTE rate after HPS (P¼ 0.653). aparin 80 mg BID for 5 days, and warfarin 10 mg daily. The Also, there was no difference between ASA 325 mg and patient received warfarin for 3 months with resolution of warfarin in regard to VTE rate after HPS (0.911). No dif- symptoms. She was doing well at her two year follow-up ference in VTE rate was observed between ASA 325 mg with no further complications. and ASA 81 mg after FAO (P¼ 0.667). Furthermore, no One 44-year-old male patient had symptomatic DVT difference in VTE rate was observed between ASA 325 mg after an FAO. The patient was discharged on aspirin and ASA 81 mg after PAO (P¼ 0.516) (Table IV). 325 mg BID. He developed pain and swelling in his lower One 42-year-old female patient developed a DVT and extremity. The DVT was diagnosed with lower extremity PE after PAO. The patient was discharged on aspirin ultrasound and the patient was treated with warfarin for 325 mg BID. She developed episodic transient stabbing 3 months with resolution of symptoms and no further pain in the popliteal fossa and intermittent episodes of complications. chest pain, palpitation, diaphoresis and shortness of breath DISCUSSION 5 days post-operatively. Her symptoms progressed, and she was admitted to the emergency room on post-operative HPS is a popular and effective surgical procedure for the day 17. A chest X-ray was obtained which demonstrated a management of young patients with minimal arthritis prominent right pulmonary trunk. A CT scan of the thorax and symptomatic hip pathology [18]. The most effective was obtained which demonstrated a filling defect in the mode of prevention of VTE following HPS remains anterior and superior branches of the right upper lobe pul- unknown with little published on this subject matter [2–5, monary artery, consistent with PE. Ultrasound of the leg 9]. Recommendations for VTE prophylaxis are mainly Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/125/4962128 by Ed 'DeepDyve' Gillespie user on 20 June 2018 Aspirin provides adequate VTE prophylaxis after hip preservation surgery  129 based on the TJA literature [1, 6–8, 12, 13]. This is gastrointestinal problems were not evaluated in this study important as the demographics in the HPS population are and may be better evaluated in a prospective randomized different from that of the TJA population, with patients study. Lastly, a confounding variable in our study is that undergoing HPS more likely to be younger, more active, recent advances in perioperative protocols including the and healthier [9]. use of spinal anesthesia and early mobilization protocols Zaltz et al. analysed the type of prophylaxis and inci- may have reduced the rate of VTE events regardless of the dence of clinically symptomatic VTE after utilizing prophylaxis regimen [10, 11]; this is difficult to account for different methods of prophylaxis for a total of 1067 peria- due to the retrospective nature of the study, however we cetabular osteotomies [2]. They reported an overall inci- still demonstrate a very low event rate of VTE in this pop- dence of VTE to be 0.94%. Polkowski et al. studied the ulation (only two events in this study). frequency of thromboembolic disease in adult patients In conclusion, this study suggests that aspirin is a safe undergoing PAO and receiving aspirin twice daily as well and an effective modality in minimizing the risk of VTE in as mechanical prophylaxis by assessing an ultrasound at patients undergoing HPS including PAO. 1 week post-operatively [3]. They found a 1.3% rate of DVT on routine screening of 136 hips, with a mean patient CONFLICT OF INTEREST STATEMENT age of 30 years (range 18–60 years). They concluded that None declared. routine post-operative screening did not detect any patients with an asymptomatic DVT. Bryan et al. reported a thromboembolic disease rate of 2 out of 75 (2.67%) REFERENCES patients receiving ASA 325 mg twice daily as well as mechanical prophylaxis after undergoing a Bernese PAO 1. Falck-Ytter Y, Francis CW, Johanson NA et al. 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Journal

Journal of Hip Preservation Surgery – Oxford University Press

Published: Apr 5, 2018

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