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Wheeless' Textbook of Orthopaedics

DVT/PE Prophylaxis in THR


- See 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 (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% ); 
            - Mortality and fatal pulmonary embolism after primary total hip replacement. Results from a regional hip register.
            - Death and thromboembolic disease after total hip replacement. A series of 1162 cases with no routine chemical prophylaxis.
    - risks of rehospitalization:
           - in the study by White, et al (2000) 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 Total Hip Arthroplasty.  
                  - Thromboembolic Disease after Total Hip Arthroplasty: Who is at Risk?
    - 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; 
               - Recent Advances in Venous Thromboembolic Prophylaxis During and After Total Hip Replacement

    - how long should prophylaxis be given?
          - in the report by Comp PC, 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:
               - Prolonged enoxaparin therapy to prevent venous thromboembolism after primary hip or knee replacement. Enoxaparin Clinical Trial Group.   
               - The Cost-Effectiveness of Extended-Duration Antithrombotic Prophylaxis After Total Hip Arthroplasty.


- Diagnostic Methods:
    - references:
          - B-mode ultrasound scanning in the detection of proximal venous thrombosis after total hip replacement.
          - Duplex scanning versus venography as a screening examination in total hip arthroplasty patients.


- Prophylactic Agents:
    - aspirin:
          - references:
                 - Aspirin prophylaxis and surveillance of pulmonary embolism and deep vein thrombosis in total hip arthroplasty.
                 - Thromboembolic Disease Prophylaxis in Total Hip Arthroplasty.
    - 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 orthopaedic patients.  
          - in a total hip arthroplasty study by Colwell, et al (1999), 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: 
                 - Comparison of enoxaparin and warfarin for the prevention of venous thromboembolic disease after total hip arthroplasty. Evaluation during hospitalization and three months after discharge.
                 - Dihydroergotamine/heparin in the prevention of deep-vein thrombosis after total hip replacement. A controlled, prospective, randomized multicenter trial
                 - The effect of intravenous fixed-dose heparin during total hip arthroplasty on the incidence of deep-vein thrombosis. A randomized, double-blind trial in patients operated on with epidural anesthesia and controlled hypotension.  
                 - Prevention of venous thrombosis after total hip arthroplasty. Antithrombin III and low-dose heparin compared with dextran 40.
                 - Complications of heparin therapy after total joint arthroplasty.
                 - Intraoperative heparin thromboembolic prophylaxis in primary total hip arthroplasty. A prospective, randomized, controlled, clinical trial.
                 - Prevention of deep-vein thrombosis and pulmonary embolism after total hip replacement. Comparison of low-molecular-weight heparin and unfractionated heparin. 
                 - Intraoperative adjusted-dose heparin thromboembolic prophylaxis in primary total hip arthroplasty.
                 - Intraoperative heparin thromboembolic prophylaxis in primary total hip arthroplasty. A prospective, randomized, controlled, clinical trial.
                 - Efficacy and safety of enoxaparin to prevent deep vein thrombosis after hip arthroplasty.
                 - Recent Advances in Venous Thromboembolic Prophylaxis During and After Total Hip Replacement.   
                 - Prolonged enoxaparin therapy to prevent venous thromboembolism after primary hip or knee replacement. Enoxaparin Clinical Trial Group. 
    - pentasaccharides:
           - in the report by Turpie AG, 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;
                 - double-blind study, patients had doses of one of five daily doses of Org31540/SR90107A, given qd, or to 30 mg of enoxaparin, given q 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 groups assigned to 0.75 mg, 1.5 mg, 3.0 mg, 6.0 mg, and 8.0 mg of drug, as compared with a rate of 9.4 % in enoxaparin group; 
                 - reduction in risk of venous thromboembolism was 82 % for 3.0-mg Org31540/SR90107A group (P=0.01) and 29 % for 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 
    - warfarin:
          - references:
                 - Routine use of adjusted low-dose warfarin to prevent venous thromboembolism after total hip replacement.
                 - Warfarin prophylaxis to prevent mortality from pulmonary embolism after total hip replacement.
                 - 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
                 - Pulmonary embolism in total hip and knee arthroplasty. Risk factors in patients on warfarin prophylaxis and analysis of the prothrombin time as an indicator of warfarin's prophylactic effect.
    - compressive devices:
          - references:
                 - Intermittent pneumatic compression to prevent proximal deep venous thrombosis during and after total hip replacement. A prospective, randomized study of compression alone, compression and aspirin, and compression and low-dose warfarin. 
                 - Intermittent pneumatic compression versus coumadin. Prevention of deep vein thrombosis in lower-extremity total joint arthroplasty
                 - Thrombosis prevention after total hip arthroplasty: a prospective, randomized trial comparing a mobile compression device with low-molecular-weight heparin. 
    - vena cava filter:
          - reference:
                 - 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 Lawton RL and Morrey BF (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;
            - The use of heparin in patients in whom a pulmonary embolism is suspected after total hip arthroplasty.



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 after primary total hip replacement. Results from a regional hip register.

Death and thromboembolic disease after total hip replacement. A series of 1162 cases with no routine chemical prophylaxis.

Thromboprophylaxis and death after total hip replacement

Comparison of enoxaparin and warfarin for the prevention of venous thromboembolic disease after total hip arthroplasty. Evaluation during hospitalization and three months after discharge.  

Rivaroxaban versus Enoxaparin for Thromboprophylaxis after Hip Arthroplasty

Death rate from pulmonary embolism following joint replacement surgery.  

Danish hip arthroplasty data show that thromboembolic events occurred on average 22 days following surgery



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

Last updated by on Friday, May 18, 2012 12:13 pm

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