Prospects for pharmacoprophylaxis of thromboembolic complications after total knee arthroplasty in patients with osteoporosis: clinical and pathogenetic aspects

Background: Prevention of thromboembolic complications is a pressing issue in pharmacology. Its importance in orthopedics is driven by the increasing number of joint arthroplasties performed year after year. Existing thromboprophylaxis regimens and recommendations take into account many risk factors. However, a number of diseases and conditions whose role in the development of thromboembolic complications has not been fully elucidated. This study demonstrates the influence of hyperhomocysteinemia in osteoporosis on the incidence of these complications after total knee arthroplasty. The clinical and pathogenetic aspects of thrombosis development in this patient group are presented. Risk stratification for these complications is substantiated, with recommendations for prolonged pharmacoprophylaxis in patients with osteoporosis and hyperhomocysteinemia.

Objective: Evaluation of the influence of bone density on the development of venous thromboembolic complications after total knee arthroplasty (TKA).

Materials and methods: Eighty patients after total knee arthroplasty were examined. D-dimer levels were determined pre- and postoperatively using an immunoturbidimetric method. Plasma homocysteine levels were also measured using an enzymatic method. Bone mineral density was assessed using densitometry of the proximal femurs and lumbar spine. The results were evaluated using the T-score. Microsoft Excel 2016 and Statistica 10.0 were used for data processing.

Results: The study found that hyperhomocysteinemia occurred exclusively in the group of patients with osteoporosis. In patients with normal bone density and osteopenia, homocysteine concentrations did not exceed the reference range. Osteoporosis in patients is accompanied by higher mean preoperative homocysteine levels compared to patients with normal bone density and osteopenia. Women with osteoporosis and elevated homocysteine levels are at higher risk of thromboembolic complications after total knee arthroplasty. Group II patients with preoperative hyperhomocysteinemia who experienced thromboembolic complications after arthroplasty have a more pronounced increase in D-dimer levels on day 7 postoperatively. This may serve as a basis for revising existing thromboprophylaxis regimens quantitatively, with a view to prolonging the duration of anticoagulant treatment and qualitatively increasing the use of non-pharmacological thromboprophylaxis methods in patients of this group. Given the statistically significant higher incidence of VTEC after TKA, more careful patient selection for surgical treatment is necessary, with recommendations for treating this condition until the quantitative BMD indicator (T-score) improves to ≥-2.5 SD. This study found that hyperhomocysteinemia is not only an important predictor of osteoporosis and a risk factor for thrombosis, but also increases the incidence of VTEC after TKA in patients with osteoporosis. This phenomenon reflects the unfavorable course of osteoporosis associated with hyperhomocysteinemia and confirms several studies on the role of hyperhomocysteinemia in the pathogenesis of osteoporosis and thrombosis.

Conclusion. Given the obtained study results, further study of the impact of osteoporosis on the risk of VTEC after orthopedic surgeries other than TKA is necessary, including for the purpose of pharmacological correction of this pathology and identifying opportunities to supplement existing pharmacoprophylaxis regimens for this group of complications.