Ortho-Preferred

DVT/PE in TKR


- See:
      - DVT: General Discussion:
      - TKR menu:

- Discusion:
    - prevalence of deep-vein thrombosis after primary total knee arthroplasty has been reported to be higher than that after primary THR;
          - calf-vein thrombosis in patients treated with total knee arthroplasty is largely responsible for this difference;
    - in the study by Wakankar et al (1999) the authors prospectively studied the effect of tourniquet on TKR patients;
          - the authors found no increased risk of DVT in patients that received a tourniquet;
          - the studied could be criticized for having too few patients in order to make a reasonable conclusion;
    - references:
          - The tourniquet in total knee arthroplasty. A prospective, randomised study.
          - The significance of calf thrombi after total knee arthroplasty.
          - Vascular ultrasonography for deep vein thrombosis after total knee arthroplasty.
          - The clinical course of distal deep venous thrombosis after total hip and total knee arthroplasty, as determined with duplex ultrasonography.

- Specific Agents:
    - aspirin:
          - Lotke 1998: combination of epidural anesthesia, ASA, stockings, and early mobilization resulted in fatal PE occurances in 0.04% of TKR patients;
          - references:
                 - Pneumatic sequential-compression boots compared with aspirin prophylaxis of deep-vein thrombosis after total knee arthroplasty.
                 - DVT Prophylaxis Options: Facts and Fictions.  
    - heparin agents: (see low molecular wt agents):    
          - in TKR, w/ low molecular wt heparins relative risk reduction of DVT is about 50%;
          - controversies:
                 - in the report by Comp et al., the authors evaluated the efficacy and safety of a prolonged post-hospital regimen of enoxaparin;
                        - following elective total hip or knee replacement, 968 patients received subcutaneous enoxaparin (30 mg twice daily) for seven to ten days,
                                 and 873 were then randomized to receive three weeks of double-blind outpatient treatment with either enoxaparin (40 mg once daily) or a placebo;
                        - of the 873 randomized patients, 435 underwent elective total hip replacement and 438 underwent elective total knee replacement;
                        - enoxaparin was superior to the placebo in reducing the prevalence of venous thromboembolism in patients treated with THR;
                                 - 8.0% (eighteen) of the 224 patients treated with enoxaparin had venous thromboembolism compared
                                        with 23.2% (forty-nine) of the 211 patients treated with the placebo;
                        - enoxaparin had no significant benefit in the patients treated with knee replacement;
                                 - 38 (17.5%) of the 217 patients treated with enoxaparin had venous thromboembolism compared with 46 (20.8%) of the
                                        221 patients treated with the placebo;
                        - symptomatic PE developed in three patients, one with a hip replacement and two with a knee replacement, all had received the placebo;
                        - there was no significant difference in the prevalence of hemorrhagic episodes or other types of toxicity between the enoxaparin and placebo-treated groups;
                 - in the report by Fitzgerald et al., the authors followed 349 patients in a prospective, randomized, multicenter, open-label, parallel-group clinical trial;
                        - treatment with enoxaparin (30 mg SQ twice daily) or warfarin (adjusted) was initiated during the immediate postoperative
                                period, within eight hours after the surgery, and was continued for four to fourteen days;
                                - warfarin group: eighty (45%) of the 176 warfarin-treated patients had venous thromboembolism:
                                       - fifty-nine (34%) had distal deep-vein thrombosis;
                                       - twenty (11%), proximal deep-vein thrombosis; and one (0.6%), pulmonary embolism
                                - enoxaparin group:
                                       - DVT developed in significantly fewer (p = 0.0001) enoxaparin-treated patients (44 of 173; 25%):
                                       - 41 (24%) had distal DVT, 3 (2%) had proximal deep-vein thrombosis, and none had pulmonary embolism;
                                       - enoxaparin-treated patients also had a significantly lower prevalence of proximal DVT (p = 0.002)
                                       - clinically important operative-site hemorrhage occurred in 6 (3%) of warfarin-treated patients and 12 (7%) of enoxaparin-treated patients (p = 0.15);
          - references:
                 - Efficacy and safety of enoxaparin versus unfractionated heparin for prevention of deep venous thrombosis after elective knee arthroplasty
                 - Prolonged Enoxaparin Therapy to Prevent Venous Thromboembolism After Primary Hip or Knee Replacement
                 - Prevention of Venous Thrombolembolic Disease Following Primary Total Knee Arthroplasty.  A Randomized, Multicenter, Open-Label, Parallel-Group Comparison of Enoxaparin and Warfarin 
    
    - warfarin:
          - references:
                 - Incidence of pulmonary embolism after total knee arthroplasty with low-dose coumadin prophylaxis.
                 - Pulmonary Embolism Prophylaxis in More Than 30,000 Total Knee Arthroplasty Patients: Is There a Best Choice?
    - pneumatic compressive devices:
          - references:
                 - Pneumatic sequential-compression boots compared with aspirin prophylaxis of deep-vein thrombosis after total knee arthroplasty.
    - vena cava filter:
          - references:
                 - Use of the Greenfield filter to prevent fatal pulmonary embolism associated with total hip and knee arthroplasty.

- Cost:
      - monitored warfarin and LMWH best studied
      - in TKA with treatment 5-14 days, similar short term results for THA, average saving of $1254 per patient for LMWH over coumadin


Prevention of venous thrombosis after total knee arthroplasty. Comparison of antithrombin III and low-dose heparin with dextran.

Fat emboli in bilateral total knee arthroplasty. Predictive factors for neurologic manifestations.

Deep-vein thrombosis and continuous passive motion after total knee arthroplasty.

DVT Prophylaxis options: facts and fictions. 

Does anticoagulation do more harm than good? A comparison of patients treated without prophylaxis and patients treated with low-dose warfarin after total knee arthroplasty.

Epidural Hematoma Secondary to Removal of an Epidural Catheter After a Total Knee Replacement. A Case Report

Rivaroxaban versus Enoxaparin for Thromboprophylaxis after Total Knee Arthroplasty

Pulmonary Embolism Prophylaxis in More Than 30,000 Total Knee Arthroplasty Patients: Is There a Best Choice?



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, January 14, 2014 1:36 pm