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Thromboprophylaxis                                                                                                     Management


         Oral thromboprophylaxis in hip and knee                                                                                 Painful TKA secondary to metal cutaneous

         arthroplasty patients                                                                                                   sensitivity



                                                                  Evidence-based outcomes
       Dr. Ashok Suryavanshi                                                                                                  Dr. Hemant Mandovra                                        ‐  A  prospective  review  demonstrated  improved
                                                                  A  metanalysis  involving  20,618  patients  indirectly                                                                outcomes following revision total knee arthroplasty
                                                                  compared rivaroxaban and dabigatran for prevention                                                                     to a hypoallergenic component.  [1]
       M.S.Ortho,  Joint Replacement                                                                                          Joint Replacement Surgeon
                                                                  of VTE after total hip or knee arthroplasty (THA, TKA)
       Marina Grand Hospital, Surat                               [2]                                                         Medicare Hospital and Research Centre, Indore              ‐  Following revision, the reactive group (LTT positive)
                                                                                                                                                                                         saw a significant decrease in pain at 6 weeks (37.8%),
                                                                                                                                                                                         5months (37.9%) and 1-year (45.3%) post-revision (p <
                                                                  Per 1000 patients treated with rivaroxaban instead of
       Introduction                                               dabigatran 13 more had no symptomatic VTE and 17            Introduction                                               0.001).  [1]
                                                                  more experienced no bleeding.  [2]
       Direct  oral  anticoagulants  (DOACs)  have  promised                                                                  Metal cutaneous sensitivity is seen in 10-15% of the            8
       superior efficacy to low molecular weight heparins in       Evidence-based  recommendation  from  NICE  favors          population causing painful joint replacement.   [1]             6
       the prevention of venous thromboembolism (VTE) in          rivaroxaban  for  the  prevention  of  venous                                                                               4
       total hip and knee arthroplasty.   [1]                     thromboembolism in adults having elective total hip         Commonly implicated metals are nickel, cobalt, and           Pain score
                                                                  or knee replacement surgery.   [3]                          chromium, all of which are commonly found in the                2
                                                                                                                                                                             [1]
       However,  there  is  a  lack  of  data  comparing  the                                                                 majority of total knee arthroplasty (TKA) implants.             0
       different DOACs.  [1]
                                                                  Conclusion                                                  Pathogenesis                                                        At the time  revision 1  revision 2  revision 3
                                                                                                                                                                                                                         Post
                                                                                                                                                                                                              Post
                                                                                                                                                                                                                                   Post
                                                                                                                                                                                                  of surgery
       Comparing the DOACs                                        Rivaroxaban has superior efficacy in VTE prevention          A  type  IV  T-cell-mediated,  or  delayed  type,                  Figure 1- Improvement in pain scores in reactive metal-LTT group
                                                                                                                                                                                                              after revision TKA  [1]
                                                                  over apixaban and dabigatran, whilst no significant          hypersensitivity reaction is seen.  [1]
       A  study  demonstrated  the  clinical  efficacy  of         difference is observed in major bleeding with any of
       rivaroxaban,  dabigatran,  and  apixaban  in  VTE          these agents.                                               The metal particles act as antigens to cross-react with       Walking function, and range of motion also
       prophylaxis and primary safety outcomes.  [1]                                                                          proteins  triggering  an  immune  response  from  the         improve significantly with revision surgery to
                                                                                                                              local tissues.   [1]
                                                                  References                                                                                                                a hypoallergic implant.  [1]
       Rivaroxaban  had  a  statistically  significant  superior
       efficacy  for  overall  VTE  prevention  (0.8%  vs  2.6%)   1.  Highcock, A. J., As-Sultany, M., Finley, R., & Donnachie, N. J.   Diagnosis
       compared with dabigatran (P < .01) and apixaban (P         (2020). A prospective cohort comparative study of rivaroxaban,                                                            Improvements in pain and range of motion
       <.01).   [1]                                               dabigatran  and  apixaban  oral  thromboprophylaxis  in  2431  hip                                                        following synovectomy, revision of the
                                                                  and knee arthroplasty patients: Primary efficacy outcomes and   Dermal patch testing -Patient’s skin is exposed to a       polyethylene insert and anti-anaphylactic
       Superior efficacy of rivaroxaban was also established       safety   profile.   The   Journal   of   arthroplasty.       variety   of   antigens   to  [1]  detect   delayed           treatment was also reported  [2]
       for  the  prevention  of  deep  vein  thrombosis           doi:10.1016/j.arth.2020.06.032                              hypersensitivity-type reaction.
       prevention (0.3% vs 2.2%) over dabigatran (P < .01).  [1]  2.   Trkulja  V,  Kolundzic  R.  Rivaroxaban  vs  dabigatran  for   Leukocyte  migration  inhibition  test  (LMIT)  -
                                                                  thromboprophylaxis   after   joint-replacement   surgery:   Measures  the  limitation  of  leukocyte  migration  by    Conclusion/ clinical implication
       The overall rate of major bleeding was 1.2% with no        exploratory  indirect  comparison  based  on  meta-analysis  of   detecting leukocyte migration inhibition factor  [2]
       significant difference observed among the 3 studied         pivotal  clinical  trials.  Croat  Med  J.  2010;51(2):113-123.                                                        Proper management of a painful TKA with positive
       drugs.   [1]                                               doi:10.3325/cmj.2010.51.113                                 Metal  lymphocyte  transformation  test  (LTT)  -          LTT  test  will  help  patients  dissatisfied  with  their
                                                                                                                              Measures the proliferation of lymphocytes activated        surgeries  and  provide  a  solution  for  their
                                                                  3.   National  Institute  of  Clinical  Excellence.  NICE  clinical                                                    unexplained pain.  [1]
       Primary outcome efficacy data for each DOAC agent.  [1]     guidelines  170:  Rivaroxaban  for  the  prevention  of  venous   by  metal  ions  and  indicates  the  cellular  immune
                                                                                                                                       [2]
                                                                  thromboembolism  after  total  hip  or  total  knee  replacement  in   function.                                       Pre-testing  patients  for  metal  sensitivity  can  detect
                                                                  adults. https://www.nice.org.uk/guidance/ta170; 2012.
                       Rivaroxaban  Dabigatran  Apixaban
            Event                                                                                                                                                                        patients  at  risk  for  developing  allergy  to  metal
                        (n = 800)  (n = 911)  (n = 720)
                                                                                                                              Management                                                 implant  and  avoid  the  morbidity  of  subsequent
        Primary end point                                                                                                                                                                revision surgeries.   [1]
            VTE          6 (0.8)    27 (3.0)   15 (2.1)                                                                       In  patients  with  known  metal  sensitivity,  primary
                                                                                                                              TKA  should  be  performed  with  hypoallergenic
                DVT      2 (0.3)    20 (2.2)   6 (0.8)
                                                                                                                              components to avoid future complications of metal
                PE       4 (0.5)    7 (0.8)    9 (1.3)                                                                                                                                   References
                                                                                                                              hypersensitivity.  [1]
            Bleeding     11 (1.4)   11 (1.2)   6 (0.8)                                                                                                                                   1.  Zondervan,  R.L.,  Vaux,  J.J.,  Blackmer,  M.J.  et  al.  Improved
                                                                                                                              A  revision  to  a  hypoallergenic  component  is          outcomes  in  patients  with  positive  metal  sensitivity  following
                                                                                                                                                                                         revision total knee arthroplasty. J Orthop Surg Res 14, 182 (2019).
                                                                                                                              recommended for patients presenting with a painful
                                                                                                                              TKA and positive metal LTT sensitivity.   [1]              2.  Bao  W,  He  Y,  Fan  Y,  Liao  Y.  Metal  allergy  in  total-joint
                                                                                                                                                                                         arthroplasty:  Case  report  and  literature  review.  Medicine
                                                                                                                                                                                         (Baltimore). 2018;97(38):e12475.
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