Postoperative Joint Replacement Complications in Swedish Patients With a Family History of Venous Thromboembolism

Importance  The associations of a family history of venous thromboembolism (FH-VTE) with postoperative venous thromboembolism (VTE) and major bleeding after joint replacement surgical procedures are unknown.

Objective  To determine the risk of VTE and major bleeding in patients after primary hip or knee replacement surgical procedures.

Design, Setting, and Participants  Cohort study using nationwide population-based databases of Swedish patients without a history of VTE who underwent joint replacement surgical procedures. Patients who had primary hip or knee replacement surgical procedures between July 1, 2005, and August 31, 2012, were identified. Patients born after 1931 without previous VTE were identified in the Swedish Multi-Generation Register. Only individuals with at least 1 parent and 1 full sibling alive between 1964 and the date for the surgical procedure were included. The data analysis was performed from September 1, 2017, to June 15, 2018.

Exposures  Family history of VTE in a parent and/or a full sibling before the date of the surgical procedure.

Main Outcomes and Measures  Venous thromboembolism and major bleeding within 90 days of the surgical procedure.

Results  Of 69 505 study participants, 37 989 (54.7%) were women, and the median (interquartile range) age at the date of discharge was 65 (59-70) years. A total of 803 of 69 505 (1.2%) patients experienced postoperative VTE and 1285 (1.8%) experienced major bleeding. The cumulative VTE risk for those with FH-VTE was 231 of 15 858 (1.5%) and for those without an FH-VTE was 572 of 53 647 (1.1%) (P < .001). The cumulative bleeding risk for those with FH-VTE was 261 of 15 858 (1.6%) and for those without an FH-VTE was 1024 of 53 647 (1.9%) (P = .03). There was an association of patients with an FH-VTE who had increased VTE risk (adjusted hazard ratio [HR], 1.36; 95% CI, 1.17-1.59) and reduced bleeding risk (adjusted HR, 0.84; 95% CI, 0.74-0.97). There was an interaction between time after discharge and FH-VTE regarding VTE and major bleeding. An FH-VTE was not associated with VTE after discharge during the first week (HR, 1.13; 95% CI, 0.86-1.49). After 7 days from discharge, FH-VTE was associated with VTE (HR, 1.49; 95% CI, 1.24-1.79). An FH-VTE reduced major bleeding risk during the first 7 days after discharge (HR, 0.78; 95% CI, 0.66-0.91) but not thereafter (HR, 1.10; 95% CI, 0.84-1.44). Postoperative VTE heritability (SE) was 20% (6%).

Conclusions and Relevance  Familial and most likely genetic factors appear to affect VTE and major bleeding risk following hip and knee replacement surgical procedures. Prolonged VTE prophylaxis might be beneficial in predisposed individuals. There may be a possible evolutionary advantage of prothrombotic genes protecting against traumatic bleeding.