Gharanizadeh Kaveh, Ravanbod Hadi, Poursalehian Mohammad, Medhat Arvin, Aminian Amir, Rajei Maziar, Hassanzadeh Mohammad, Abolghasemian Mansour
Bone and Joint Reconstruction Research Center, Department of Orthopedics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran.
Clin Orthop Relat Res. 2025 Jun 9. doi: 10.1097/CORR.0000000000003482.
Despite advancements, THA is still associated with risks, particularly venous thromboembolism (VTE). THA in patients with high-riding developmental dysplasia of the hip (DDH) could potentially be associated with an elevated risk of VTE. We conducted a study to evaluate whether patients with high-riding DDH undergoing THA and receiving aspirin have an increased risk of symptomatic VTE compared with patients undergoing primary THA for other diagnoses. Additionally, we investigated possible risk factors for VTE within this specific patient group.
QUESTIONS/PURPOSES: (1) Is the risk of symptomatic VTE (all deep vein thrombosis [DVT] plus pulmonary embolism, or proximal DVT plus pulmonary embolism) increased in patients undergoing THA for severe DDH, defined as Crowe type III or IV, compared with patients undergoing THA for other reasons when aspirin is used for prophylaxis? (2) In patients with severe DDH undergoing THA, are there specific identifiable risk factors associated with an increased risk of symptomatic VTE?
Between June and November 2021, an arthroplasty surgeon performed 153 consecutive primary THAs on 146 patients across two arthroplasty centers. All patients except those with a history of prior VTE or those on chronic anticoagulation received aspirin as pharmacologic prophylaxis for VTE. No routine surveillance for VTE was used. To be eligible for this retrospective comparative study, a chart note documenting any signs or symptoms of symptomatic VTE had to be present at least 3 months postoperatively. Patients were excluded for the following reasons: they had a personal history of VTE (1% [2 of 146]), they were receiving ongoing anticoagulant therapy (2% [3 of 146]), they were out of the age criteria range (2% [3 of 146]), they had undergone same-setting bilateral THAs or the second side of staged bilateral THAs (3% [4 of 146]), or they were lost to follow-up within 90 days after surgery (0% [0]). After exclusions, 134 patients (134 hips) remained. Patients were divided into two groups based on their preoperative diagnosis: (1) high-riding DDH of Crowe type III or IV (35% [47 of 134] of hips) and (2) all other diagnoses, including primary or inflammatory arthritis, Crowe type I or II DDH, fracture, and osteonecrosis (65% [87 of 134] of hips). A comprehensive records review was conducted to determine the incidence of symptomatic VTE, including distal DVT, proximal DVT, or pulmonary embolism. Patients' demographics, surgical details, and outcomes were compared between the groups. The high-riding group had longer operations and a higher percentage of patients having general anesthesia, acetabular bone grafting, transfusions, or restricted weightbearing postoperatively. Univariable analysis was performed to compare the high-riding DDH group with the control group and to evaluate associations between potential risk factors and symptomatic VTE. Subsequently, multivariable logistic regression was conducted to identify independent risk factors among the variables identified in the univariable analysis.
Patients undergoing THA for DDH had higher odds of experiencing symptomatic VTE compared with the control group (17% [8 of 47] versus 1% [1 of 87], OR 18 [95% confidence interval (CI) 2 to 146]; p = 0.001). After adjusting for confounding variables such as age, sex, American Society of Anesthesiologists grading, anesthesia type, operation duration, shortening osteotomy, shelf/impaction grafting, and blood transfusion, patients undergoing THA for high-riding DDH still had higher adjusted odds of symptomatic VTE compared with the other group (adjusted OR 67 [95% CI 3 to 151]; p = 0.008). When considering only proximal DVT or pulmonary embolism events (excluding distal DVT), the odds of experiencing a VTE event remained higher in patients with high-riding DDH compared with the other group (11% [5 of 47] versus 1% [1 of 87], OR 10 [95% CI 1 to 90]; p = 0.02). In patients undergoing THA for high-riding DDH, after controlling for potential confounding variables, limb lengthening was identified as the only factor associated with an increased likelihood of symptomatic VTE (median [range] lengthening 38 mm [25 to 60] versus 25 mm [15 to 50]; p = 0.002).
Our findings showed that patients undergoing THA for high-riding developmental DDH and receiving aspirin for VTE prophylaxis had a higher likelihood of experiencing symptomatic VTE, including DVT and pulmonary embolism, compared with patients undergoing primary THA for other indications. Additionally, greater intraoperative limb lengthening in this group appeared to further increase the risk of VTE. While DDH may be a risk factor for symptomatic VTE after THA, this association could also be attributed to the increased complexity of the procedure in hips with high-riding DDH. Until larger studies with multivariable analyses of potential risk factors are conducted to clarify this issue, we recommend that surgeons consider using thromboprophylaxis agents more potent than aspirin for patients undergoing THA for high-riding DDH and remain particularly vigilant in the postoperative period for signs and symptoms of VTE.
Level III, therapeutic study.
尽管取得了进展，但全髋关节置换术（THA）仍存在风险，尤其是静脉血栓栓塞（VTE）。高位发育性髋关节发育不良（DDH）患者行THA可能会增加VTE风险。我们开展了一项研究，以评估与因其他诊断行初次THA的患者相比，高位DDH患者行THA并服用阿司匹林时，发生有症状VTE的风险是否增加。此外，我们还调查了这一特定患者群体中VTE的可能危险因素。
问题/目的：（1）与因其他原因行THA且使用阿司匹林进行预防的患者相比，因严重DDH（定义为Crowe III型或IV型）行THA的患者发生有症状VTE（所有深静脉血栓形成[DVT]加肺栓塞，或近端DVT加肺栓塞）的风险是否增加？（2）在因严重DDH行THA的患者中，是否存在与有症状VTE风险增加相关且可识别的特定危险因素？
2021年6月至11月期间，一名关节置换外科医生在两个关节置换中心为146例患者连续进行了153例初次THA手术。除有VTE病史或正在接受慢性抗凝治疗的患者外，所有患者均接受阿司匹林作为VTE的药物预防。未进行VTE的常规监测。为符合这项回顾性比较研究的条件，术后至少3个月的病历记录中须有记录有症状VTE的任何体征或症状。因以下原因排除患者：有VTE个人史（1%[146例中的2例]）、正在接受抗凝治疗（2%[146例中的3例]）、超出年龄标准范围（2%[146例中的3例]）、已在同一机构进行双侧THA或分期双侧THA的第二侧手术（3%[146例中的4例]），或术后90天内失访（0%[0例]）。排除后，剩余134例患者（134髋）。根据术前诊断将患者分为两组：（1）Crowe III型或IV型高位DDH（134髋中的47髋，占35%）和（2）所有其他诊断，包括原发性或炎性关节炎、Crowe I型或II型DDH、骨折和骨坏死（134髋中的87髋，占65%）。进行全面的病历审查以确定有症状VTE的发生率，包括远端DVT、近端DVT或肺栓塞。比较两组患者的人口统计学特征、手术细节和结果。高位组手术时间更长，接受全身麻醉、髋臼植骨、输血或术后限制负重的患者比例更高。进行单变量分析以比较高位DDH组与对照组，并评估潜在危险因素与有症状VTE之间的关联。随后，进行多变量逻辑回归以确定单变量分析中确定的变量中的独立危险因素。
与对照组相比，因DDH行THA的患者发生有症状VTE的几率更高（17%[47例中的8例]对1%[87例中的1例]，OR 18[95%置信区间（CI）2至146]；p = 0.001）。在调整年龄、性别、美国麻醉医师协会分级（American Society of Anesthesiologists grading）、麻醉类型、手术持续时间、短缩截骨、髋臼加盖/打压植骨和输血等混杂变量后，与其他组相比，因高位DDH行THA的患者发生有症状VTE的调整后几率仍然更高（调整后OR 67[95% CI 3至151]；p = 0.008）。仅考虑近端DVT或肺栓塞事件（不包括远端DVT）时，与其他组相比，高位DDH患者发生VTE事件的几率仍然更高（11%[47例中的5例]对1%[87例中的1例]，OR 10[95% CI 1至90]；p = 0.02）。在因高位DDH行THA的患者中，在控制潜在混杂变量后，肢体延长被确定为与有症状VTE可能性增加相关的唯一因素（中位[范围]延长38 mm[25至60]对25 mm[15至50]；p = 0.002）。
我们的研究结果表明，与因其他适应证行初次THA的患者相比，因高位发育性DDH行THA并接受阿司匹林预防VTE的患者发生有症状VTE（包括DVT和肺栓塞）的可能性更高。此外，该组术中更大程度的肢体延长似乎进一步增加了VTE风险。虽然DDH可能是THA后有症状VTE的一个危险因素，但这种关联也可能归因于高位DDH髋关节手术复杂性的增加。在进行更大规模的研究对潜在危险因素进行多变量分析以阐明这一问题之前，我们建议外科医生考虑为因高位DDH行THA的患者使用比阿司匹林更有效的血栓预防药物，并在术后特别警惕VTE的体征和症状。
III级，治疗性研究。
Zotero 插件