Full Length ArticleSystematic review of risk prediction scores for venous thromboembolism following joint replacement
Introduction
Total joint replacement, one of the most common elective orthopaedic procedures, is a highly successful and cost-effective intervention for alleviating pain and disability associated with advanced joint disease such as osteoarthritis [1, 2]. Venous thromboembolism (VTE), which comprises pulmonary embolism (PE) and deep vein thrombosis (DVT), is a frequent complication of lower limb joint replacement. Venous thromboembolism affects several millions of people globally, it is an important cause of long-term morbidity and a preventable cause of deaths, and its management is associated with huge health costs [3]. Despite the effectiveness of anticoagulants at preventing VTE, rates ranging from 0.27% to 61.0% have been reported in patient populations undergoing lower limb replacement [4, 5].
With increasing life expectancy, there is a predicted large rise in the number of people who will be affected by joint disease and hence the number of patients undergoing primary joint replacement [6]. Despite the emergence of newer and more potent prophylactic regimens for VTE, there will also be a proportionate rise in the number of patients who will be affected by VTE. As such, the most appropriate way to tackle this is from a public health perspective – using a preventive approach. This entails identifying patients who are at high risk of developing VTE before they undergo joint replacement and developing preventative measures targeted at these high-risk groups. There are several known predisposing risk factors for VTE development following lower limb joint replacement and these include advanced age; high body mass index (BMI); smoking; and comorbidities such as cardiovascular disease, previous VTE, and cancer [[7], [8], [9]]. These established risk factors have the potential to be used to identify patients who are at high risk of VTE and can also be combined within a risk prediction score or prognostic model to predict VTE outcome risk for individuals. A risk prediction score is a statistical equation that uses multiple prognostic or risk factors in a formal combination to estimate the individualised probability or risk that a certain condition or disease will occur in the future [10]. Given that the risk of VTE development after lower limb joint replacement varies between individuals, there is an interest in developing individualised risk prediction scores for VTE risk; however, little progress has been made in the area. Much research has been focussed on the identification of risk or prognostic factors for VTE in joint replacement patients [11]. Published studies have mostly reported on measures of the strength of the association (e.g., odds ratios, risk ratios, hazard ratios), which do not address the accuracy of these factors in classifying or predicting risk of VTE in individuals following joint replacement [12].
Prevention of VTE following lower limb replacement is a high policy priority and no single risk prediction score has as yet been recommended as being optimal for VTE risk prediction in orthopaedic practice. It is also known that there is often conflicting evidence about the predictive performance of developed risk prediction scores [13]. To our knowledge, there is no summarised evidence on existing risk scores (including their component variables), their predictive performance, and whether their clinical effectiveness have been assessed in well-designed randomised controlled trials (RCTs). In this context, we aimed to systematically review all the available evidence on risk prediction scores for VTE following hip and/or knee replacement. The specific objectives were to: (i) assess clinical variables selected for model inclusion and the predictive performance of these models; (ii) assess if identified models have been externally validated and their performances compared; (iii) assess if the clinical effectiveness of these scores have been evaluated in appropriate RCTs; and (iv) to identify gaps in the existing evidence and whether further research is needed in the field. Our findings should inform clinical practice by identifying host, surgical, and laboratory characteristics that show consistent evidence of prognostic significance and should inform further research in this area.
Section snippets
Data sources and search strategy
We conducted this review in accordance with the CHARMS checklist [14] and PRISMA guidelines [15], (Appendix A) and using a predefined protocol, which has been registered in the PROSPERO prospective register of systematic reviews (CRD42018088712). We searched for eligible studies in MEDLINE, Embase, Web of Science, and The Cochrane Library electronic databases from inception up to 20 April 2018. The computer-based search strategy combined free and MeSH search terms and combination of key words
Study identification and selection
The flow of studies through the screening and selection process is shown in Fig. 1. The literature search strategy identified 603 potentially relevant articles. After an initial screen of titles and abstracts, 11 articles were selected for full text evaluation. Following detailed evaluation, six articles were excluded because (i) they did not report development and/or validation of a specific risk prediction score (n = 4); (ii) the population was not relevant (n = 1); and (iii) the outcome was
Key findings
This systematic review of available risk prediction scores for VTE following hip and knee replacement identified five studies, all published in the last six years. Three studies reported the development of three independent risk scores [[20], [21], [22]], whereas two studies evaluated existing scores originally developed for different populations or outcomes [23, 24]. Only two studies reported on the definitions used for VTE outcomes [20, 22]. The number of component variables for the five risk
Conclusions
Only a small number of risk scores to predict VTE in hip and knee joint replacement patients have been developed and these have several limitations. The existing risk scores have been developed using inadequate methodology, have been inadequately reported, not been sufficiently validated, and their impact on patient outcomes and decision making is unknown. The ACS-NSQIP-derived risk stratification system may have some potential for use in clinical practice; however, inadequate methodology was
Funding sources
This study was supported by the NIHR Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care.
Declarations of interest
None.
References (50)
- et al.
Comparative outcomes of total joint arthroplasty
J. Arthroplast.
(1995) - et al.
Timing of symptomatic pulmonary embolism with warfarin following arthroplasty
J. Arthroplast.
(2015) - et al.
Individualized risk model for venous thromboembolism after total joint arthroplasty
J. Arthroplast.
(2016) - et al.
Development and validation of a risk stratification system for pulmonary embolism after elective primary total joint arthroplasty
J. Arthroplast.
(2016) - et al.
Correlation of the Caprini Score and venous thromboembolism incidence following primary total joint arthroplasty-results of a single-institution protocol
J. Arthroplast.
(2017) - et al.
Using the Risk Assessment and Predictor Tool (RAPT) for patients after total knee replacement surgery
Ann. Phys. Rehabil. Med.
(2012) - et al.
Predicting risk of extended inpatient rehabilitation after hip or knee arthroplasty
J. Arthroplast.
(2003) - et al.
Internal and external validation of predictive models: a simulation study of bias and precision in small samples
J. Clin. Epidemiol.
(2003) - et al.
Risk assessment tools for detecting those with pre-diabetes: a systematic review
Diabetes Res. Clin. Pract.
(2014) Thrombosis risk assessment as a guide to quality patient care
Dis. Mon.
(2005)
Effective risk stratification of surgical and nonsurgical patients for venous thromboembolic disease
Semin. Hematol.
Validation of the Caprini risk assessment model in plastic and reconstructive surgery patients
J. Am. Coll. Surg.
Risk factors for venous thrombosis in medical inpatients: validation of a thrombosis risk score
J. Thromb. Haemost.
Outcomes of total hip and knee replacement: preoperative functional status predicts outcomes at six months after surgery
Arthritis Rheum.
Statins for primary prevention of venous thromboembolism
Cochrane Database Syst. Rev.
Effect of genotype-guided warfarin dosing on clinical events and anticoagulation control among patients undergoing hip or knee arthroplasty: the GIFT randomized clinical trial
JAMA
Incidence and risk factors of deep vein thrombosis (DVT) after total hip or knee arthroplasty: a retrospective study with routinely applied venography
Blood Coagul. Fibrinolysis
Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030
Clin. Orthop.
Factors that predict short-term complication rates after total hip arthroplasty
Clin. Orthop.
Risk factors for pulmonary embolism after hip and knee arthroplasty: a population-based study
Int. Orthop.
Risk factors for venous thromboembolism after total hip and knee replacement surgery
Curr. Opin. Pulm. Med.
Prognosis Research Strategy (PROGRESS) 3: prognostic model research
PLoS Med.
Risk factors for venous thromboembolism after total hip and total knee arthroplasty: a meta-analysis
Arch. Orthop. Trauma Surg.
Statistical methods for assessment of added usefulness of new biomarkers
Clin. Chem. Lab. Med.
A guide to systematic review and meta-analysis of prediction model performance
BMJ
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