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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.