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Total Hip Replacement Menu:
- Discussion: (
general discussion of DVT)
- 40-60% of THR patients who do not receive prophylaxis will get a DVT (dependment on imaging method);
- ref:
Significance of deep venous thrombosis in the lower extremity after total joint arthroplasty.
- in contrast, the study by
Fender et al (JBJS 1997) showed that the incidence of fatal PE (as diagnosed by postmortem examination) was 4 / 2111 patients (0.19%);
- in this study, use of chemical prophylactic agents had no impact on the occurance of a fatal PE (3 patients that died
had been on chemical prophylactic agents and one patient died that had no prophylaxis);
- these authors feel that the issue can only be solved by a large scale prospective randomized trial (tens of thousands of patients);
- supporting this data, is the study by
Warwick et al which showed one fatal PE out of 1162 consecutive total hip replacements (death rate from PE was 0.34% );
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risks of rehospitalization:
- in the study by White et al (N Engl J Med 2000;343:1758-64) identified 297 patients 65 years of age or older who were
rehospitalized for thromboembolism within 3 months after THR;
- total of 89.6% with thromboembolism and 93.8 % of controls were treated w/ SCDs, warfarin, enoxaparin, or unfractionated heparin, alone or in combination;
- 22.2 % and 29.7 %, respectively, received warfarin after discharge;
- body-mass index (wt in kg divided by square of ht in meters) of 25 or greater was associated w/ rehospitalization for thromboembolism, w/ odds ratio of 2.5;
- Predictors of Rehospitalization for Symptomatic Venous Thromboembolism after THR. White et al. NEJM. December 14, 2000 Vol. 343, No. 24
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Thromboembolic Disease after Total Hip Arthroplasty: Who is at Risk?
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when is prophylaxis to be initiated?
- in the review article by Salvati et al, the authors point out that timing of heparin administration may be critcal for DVT prophylaxis;
- they point out that thrombogenesis begins during the preparation of the femur and is most pronounced with implantation of femoral components
with cement rather than without cement;
- in this phase, thrombotic mediators are released which leads to femoral venous occlusion occurs;
- the authors recommend giving a bolus of IV heparin (approx 3000 units) just before cement preparation of the femur;
- because the half life of IV heparin is short (approx 30-40 min), risk of significant bleeding is minimal;
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how long should prophylaxis be given?
- in the report by
Philip C. Comp et al, the authors evaluated the efficacy and safety of a prolonged post-hospital regimen of enoxaparin;
- following elective THR or TKR, 968 patients received subcutaneous enoxaparin (30 mg twice daily) for 7-10 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;
- enoxaparin was superior to the placebo in reducing the prevalence of venous thromboembolism in patients treated with THR;
- 8.0% of patients treated with enoxaparin had DVT compared with 23.2% of patients treated with the placebo;
- enoxaparin had no significant benefit in the patients treated with knee replacement;
- 17.5% of the patients treated with enoxaparin had DVT compared with 46 20.8% of 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;
- references:
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Prolonged Enoxaparin Therapy to Prevent Venous Thromboembolism After Primary Hip or Knee Replacement.
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The Cost-Effectiveness of Extended-Duration Antithrombotic Prophylaxis After Total Hip Arthroplasty.
- Diagnostic Methods:
- references:
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B-mode ultrasound scanning in the detection of proximal venous thrombosis after total hip replacement.
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Duplex scanning versus venography as a screening examination in total hip arthroplasty patients.
- Prophylactic Agents:
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aspirin:
- references:
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Aspirin prophylaxis and surveillance of pulmonary embolism and deep vein thrombosis in total hip arthroplasty.
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Thromboembolic Disease Prophylaxis in Total Hip Arthroplasty.
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heparin and low molecular wt agents:
- in THR, relative risk reduction for DVT using LMWHs is about 70%;
- even with use of low molecular wt heparins, the risk of DVT following THR may be as high as 15%;
- ref: Finding the right fit: Effective thrombosis risk stratification in orthopeadic patients. JI Arcelus MD PhD et al. Orthopedics. Jun 2000. Vol 23. No 6. p 633.
- in a total hip arthroplasty study by Colwell et al (JBJS July 1999, Vol 81-A), the overall rate of throboembolic disease was 3.6% for patients receiving
lovenox versus 3.7 % for patients receiving adjusted dose coumadin;
- lovenox (or coumadin) was continued only for the length of the primary hospitalization (which averaged 7 days;
- references:
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Dihydroergotamine/heparin in the prevention of deep-vein thrombosis after total hip replacement. A controlled, prospective, randomized multicenter trial;
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The effect of IV fixed-dose heparin during THR on the incidence of DVT. A randomized, double-blind trial in patients operated
on with epidural anesthesia and controlled hypotension.
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Prevention of venous thrombosis after total hip arthroplasty. Antithrombin III and low-dose heparin compared with dextran 40.
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Complications of heparin therapy after total joint arthroplasty.
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Intraoperative heparin thromboembolic prophylaxis in primary total hip arthroplasty. A prospective, randomized, controlled, clinical trial.
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Prevention of DVT and PE after THR. Comparison of low-molecular-weight heparin and unfractionated heparin.
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Intraoperative adjusted-dose heparin thromboembolic prophylaxis in primary total hip arthroplasty.
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Intraoperative heparin thromboembolic prophylaxis in primary total hip arthroplasty. A prospective, randomized, controlled, clinical trial.
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Efficacy and safety of enoxaparin to prevent deep vein thrombosis after hip arthroplasty.
- Recent Advances in Venous Thromboembolic Prophylaxis During and After THR. EA Salvati MD. JBJS-Am Feb 2000 Vol 82-A, No 2 Page 252
- Prolonged Enoxaparin Therapy to Prevent Venous Thromboembolism After Primary Hip or Knee Replacement
Philip C. Comp, MD, PhD. J Bone Joint Surg [Am] 83-A: 336-45, 2001
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pentasaccharides:
- in the report by G.G Alexander et al., the authors studied the effects of the pentasaccharide Org31540/SR90107A,
a highly selective, indirect inhibitor of activated factor X, is the first of a new class of synthetic antithrombotic agents;
- in a double-blind study, patients were randomly assigned to postoperative administration of one of five daily
doses of Org31540/SR90107A, given once daily, or to 30 mg of enoxaparin, given every 12 hours;
- treatment was continued for 10 days or until bilateral venography was performed after a minimum of 5 days;
- of 933 patients treated, 593 were eligible for the efficacy analysis;
- with Org31540/SR90107A a dose effect was observed (P=0.002), with rates of venous thromboembolism of 11.8 %,
6.7 %, 1.7 %, 4.4 %, and 0 % for the groups assigned to 0.75 mg, 1.5 mg, 3.0 mg, 6.0 mg, and 8.0 mg of
the drug, respectively, as compared with a rate of 9.4 % in the enoxaparin group;
- reduction in the risk of venous thromboembolism was 82 percent for the 3.0-mg Org31540/SR90107A group (P=0.01) and
29 percent for the 1.5-mg group (P=0.51);
- enrollment in the 6.0-mg and 8.0-mg Org31540/SR90107A groups was discontinued because of bleeding complications;
- major bleeding occurred 3.5 percent less frequently in the 0.75-mg group (P=0.01) and 3.0 percent less frequently
in the 1.5-mg group (P=0.05) than in the enoxaparin group (in which the rate was similar to that in the 3.0-mg group);
- the authors concluded that Org31540/SR90107A, a synthetic pentasaccharide, has the potential to improve significantly the risk-benefit
ratio for the prevention of venous thromboembolism, as compared with low-molecular-weight heparin.
- ref: A Synthetic Pentasaccharide for the Prevention of Deep-Vein Thrombosis after Total Hip Replacement
G.G Alexander et al. The New England Journal of Medicine -- March 1, 2001 -- Vol. 344, No. 9
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warfarin:
- references:
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Routine use of adjusted low-dose warfarin to prevent venous thromboembolism after total hip replacement.
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Warfarin prophylaxis to prevent mortality from pulmonary embolism after total hip replacement.
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Intermittent pneumatic compression versus coumadin. Prevention of deep vein thrombosis in lower-extremity total joint arthroplasty.
- Prevention of deep venous thrombosis after total hip arthroplasty. Comparison of warfarin and dalteparin.
CW Francis MD et al. JBJS. Vol 79-A. No 9. Sep 1997. p 1365.
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PE in THR and TKR arthroplasty. Risk factors in patients on warfarin prophylaxis and analysis of the PT as an indicator of warfarin's prophylactic effect.
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compressive devices:
- references:
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Intermittent Pneumatic Compression to prevent DVT during and after THR.
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Intermittent pneumatic compression versus coumadin. Prevention of deep vein thrombosis in lower-extremity total joint arthroplasty.
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vena cava filter:
- references:
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Use of the Greenfield filter to prevent fatal pulmonary embolism associated with total hip and knee arthroplasty.
- Treatment:
- standard treatment algorithm (confirmation of DVT/PE, followed by IV heparin or SQ low molecular wt heparin, followed by PO warfarin;
- consider applying a hip spica compression dressing (from toes to waist) to reduce swelling and risk of hematoma;
- in the report by RL Lawtom and BF Morrey (JBJS Vol 81-A, No 8, Aug 1999), the authors advise that patients who demonstrate clinical signs of a PE
should have the diagnosis confirmed before starting empiric IV heparin;
- they noted at 47% complication rate in their patients (versus 20% in patients that did not receive heparin);
- they found no benefit to starting IV heparin prior to confirmation of the diagnosis;
Prevention of venous thrombosis after total hip arthroplasty. Antithrombin III and low-dose heparin compared with dextran 40.
The effect of total hip replacement and general surgery on antithrombin III in relation to venous thrombosis.
Total hip replacement, lower limb blood flow and venous thrombogenesis.
Mortality and fatal pulmonary embolism post primary total hip replacement: results from a region hip register.
D. Fender et al. JBJS Vol 79-B. 1997. p 896-899.
Death and thromboembolic disease after total hip replacement: a series of 1162 cases with no routine chemical prophlaxis.
D. Warwick et al. JBJS Vol 77-B. 1995. p 6-10.
Thromboprophylaxis and death after total hip replacement. DW Murray et al. JBJS Vol 78-B. 1995. p 863.
Comparison of Enoxaparin and Warfarin for the Prevention of Venous Thromboembolic Disease After THR. Evaluation During Hospitalization and 3 Months After Discharge
CW Colwell et al JBJS July 1999, Vol 81-A, No 7.
Rivaroxaban versus Enoxaparin for Thromboprophylaxis after Hip Arthroplasty
