A dedicated anticoagulation clinic does not improve postoperative management of warfarin after total joint arthroplasty

Joshua S. Bingham, Christopher G. Salib, Kyle Labban, Zachary Morrison, Mark J. Spangehl

Research output: Contribution to journalArticle

3 Citations (Scopus)

Abstract

Background: Periprosthetic joint infections (PJIs) are devastating complications. Excessive anticoagulation with warfarin is an independent risk factor for PJIs. The use of a dedicated anticoagulation clinic to improve warfarin management has not been proven. Methods: Between 2006 and 2014, we identified 92 patients who were placed on postoperative warfarin, and later developed PJI. These patients were compared to 313 patients who underwent total joint arthroplasty placed on warfarin without developing PJI. Patients were included if they had no history of a venous thromboembolic event, were warfarin naive, and enrolled in the anticoagulation clinic. A univariate analysis compared independent variables, and statistical analysis was performed using Student's t-test and Pearson chi-square test for continuous and categorical variables. Results: Thirty-six PJI patients and 297 control patients met the inclusion criteria. The venous thromboembolism rate was 2.1%. At discharge, 82% of all patients were subtherapeutic. Patients were within their target international normalized ratio (INR) range 26.7% of the time. The mean INR in the initial postoperative period for the PJI group was 1.46 and 1.29 in the control group (P <.001). In the acute postoperative period, 13.3% of the knee PJI group were therapeutic or supratherapeutic compared with 3.5% in the knee control group (P =.002). Conclusions: Despite utilization of a dedicated anticoagulation clinic, patients were only within their target INR range 27% of the time. Total knee arthroplasty patients who developed a PJI were more likely to be therapeutic or supratherapeutic in the initial postoperative period. Consequently, the risks associated with warfarin as a venous thromboembolism prophylaxis may outweigh the potential benefits.

Original languageEnglish (US)
JournalArthroplasty Today
DOIs
StateAccepted/In press - Jan 1 2018

Fingerprint

Warfarin
Arthroplasty
Joints
Infection
International Normalized Ratio
Postoperative Period
Venous Thromboembolism
Knee Replacement Arthroplasties
Control Groups
Chi-Square Distribution
Knee Joint
Knee
Students

Keywords

  • International normalized ratio (INR)
  • Periprosthetic joint infection (PJI)
  • Pulmonary emboli (PE)
  • Total joint arthroplasty (TJA)
  • Venous thromboembolism (VTE)
  • Warfarin

ASJC Scopus subject areas

  • Surgery
  • Orthopedics and Sports Medicine

Cite this

A dedicated anticoagulation clinic does not improve postoperative management of warfarin after total joint arthroplasty. / Bingham, Joshua S.; Salib, Christopher G.; Labban, Kyle; Morrison, Zachary; Spangehl, Mark J.

In: Arthroplasty Today, 01.01.2018.

Research output: Contribution to journalArticle

Bingham, Joshua S. ; Salib, Christopher G. ; Labban, Kyle ; Morrison, Zachary ; Spangehl, Mark J. / A dedicated anticoagulation clinic does not improve postoperative management of warfarin after total joint arthroplasty. In: Arthroplasty Today. 2018.
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abstract = "Background: Periprosthetic joint infections (PJIs) are devastating complications. Excessive anticoagulation with warfarin is an independent risk factor for PJIs. The use of a dedicated anticoagulation clinic to improve warfarin management has not been proven. Methods: Between 2006 and 2014, we identified 92 patients who were placed on postoperative warfarin, and later developed PJI. These patients were compared to 313 patients who underwent total joint arthroplasty placed on warfarin without developing PJI. Patients were included if they had no history of a venous thromboembolic event, were warfarin naive, and enrolled in the anticoagulation clinic. A univariate analysis compared independent variables, and statistical analysis was performed using Student's t-test and Pearson chi-square test for continuous and categorical variables. Results: Thirty-six PJI patients and 297 control patients met the inclusion criteria. The venous thromboembolism rate was 2.1{\%}. At discharge, 82{\%} of all patients were subtherapeutic. Patients were within their target international normalized ratio (INR) range 26.7{\%} of the time. The mean INR in the initial postoperative period for the PJI group was 1.46 and 1.29 in the control group (P <.001). In the acute postoperative period, 13.3{\%} of the knee PJI group were therapeutic or supratherapeutic compared with 3.5{\%} in the knee control group (P =.002). Conclusions: Despite utilization of a dedicated anticoagulation clinic, patients were only within their target INR range 27{\%} of the time. Total knee arthroplasty patients who developed a PJI were more likely to be therapeutic or supratherapeutic in the initial postoperative period. Consequently, the risks associated with warfarin as a venous thromboembolism prophylaxis may outweigh the potential benefits.",
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AU - Bingham, Joshua S.

AU - Salib, Christopher G.

AU - Labban, Kyle

AU - Morrison, Zachary

AU - Spangehl, Mark J.

PY - 2018/1/1

Y1 - 2018/1/1

N2 - Background: Periprosthetic joint infections (PJIs) are devastating complications. Excessive anticoagulation with warfarin is an independent risk factor for PJIs. The use of a dedicated anticoagulation clinic to improve warfarin management has not been proven. Methods: Between 2006 and 2014, we identified 92 patients who were placed on postoperative warfarin, and later developed PJI. These patients were compared to 313 patients who underwent total joint arthroplasty placed on warfarin without developing PJI. Patients were included if they had no history of a venous thromboembolic event, were warfarin naive, and enrolled in the anticoagulation clinic. A univariate analysis compared independent variables, and statistical analysis was performed using Student's t-test and Pearson chi-square test for continuous and categorical variables. Results: Thirty-six PJI patients and 297 control patients met the inclusion criteria. The venous thromboembolism rate was 2.1%. At discharge, 82% of all patients were subtherapeutic. Patients were within their target international normalized ratio (INR) range 26.7% of the time. The mean INR in the initial postoperative period for the PJI group was 1.46 and 1.29 in the control group (P <.001). In the acute postoperative period, 13.3% of the knee PJI group were therapeutic or supratherapeutic compared with 3.5% in the knee control group (P =.002). Conclusions: Despite utilization of a dedicated anticoagulation clinic, patients were only within their target INR range 27% of the time. Total knee arthroplasty patients who developed a PJI were more likely to be therapeutic or supratherapeutic in the initial postoperative period. Consequently, the risks associated with warfarin as a venous thromboembolism prophylaxis may outweigh the potential benefits.

AB - Background: Periprosthetic joint infections (PJIs) are devastating complications. Excessive anticoagulation with warfarin is an independent risk factor for PJIs. The use of a dedicated anticoagulation clinic to improve warfarin management has not been proven. Methods: Between 2006 and 2014, we identified 92 patients who were placed on postoperative warfarin, and later developed PJI. These patients were compared to 313 patients who underwent total joint arthroplasty placed on warfarin without developing PJI. Patients were included if they had no history of a venous thromboembolic event, were warfarin naive, and enrolled in the anticoagulation clinic. A univariate analysis compared independent variables, and statistical analysis was performed using Student's t-test and Pearson chi-square test for continuous and categorical variables. Results: Thirty-six PJI patients and 297 control patients met the inclusion criteria. The venous thromboembolism rate was 2.1%. At discharge, 82% of all patients were subtherapeutic. Patients were within their target international normalized ratio (INR) range 26.7% of the time. The mean INR in the initial postoperative period for the PJI group was 1.46 and 1.29 in the control group (P <.001). In the acute postoperative period, 13.3% of the knee PJI group were therapeutic or supratherapeutic compared with 3.5% in the knee control group (P =.002). Conclusions: Despite utilization of a dedicated anticoagulation clinic, patients were only within their target INR range 27% of the time. Total knee arthroplasty patients who developed a PJI were more likely to be therapeutic or supratherapeutic in the initial postoperative period. Consequently, the risks associated with warfarin as a venous thromboembolism prophylaxis may outweigh the potential benefits.

KW - International normalized ratio (INR)

KW - Periprosthetic joint infection (PJI)

KW - Pulmonary emboli (PE)

KW - Total joint arthroplasty (TJA)

KW - Venous thromboembolism (VTE)

KW - Warfarin

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