• overview
  • 40-60% of THA patients who do not receive prophylaxis will get a DVT (dependent on imaging method)
    • reference - 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 who had been on chemical prophylactic agents died and one patient who had no prophylaxis died)
    • the 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 of 1,162 consecutive total hip replacements (death rate from PE was 0.34%)
    • references - 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 THA
    • 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
  • references - Predictors of rehospitalization for symptomatic venous thromboembolism after total hip arthroplasty.
  • Thromboembolic disease after total hip arthroplasty: who is at risk?
  • Complication rates after hip or knee arthroplasty in morbidly obese patients. 
  • Incidence of neuraxial haematoma after total hip or knee surgery: RECORD programme (rivaroxaban vs. enoxaparin). 

Total knee replacement (TKA)

• overview
  • prevalence of deep-vein thrombosis after primary total knee arthroplasty has been reported to be higher than that after primary THA
    • 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 study could be criticized for having too few patients to make a reasonable conclusion
    • reference - 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.
  • Complication rates after hip or knee arthroplasty in morbidly obese patients. 
  • Incidence of neuraxial haematoma after total hip or knee surgery: RECORD programme (rivaroxaban vs. enoxaparin).

Trauma, Pelvic Fractures, and Extremity Fractures

• overview
  • 30-50 % occurence of DVT in trauma pts w/ lower extremity fractures
  • preexisting conditions such as heart disease, obesity, carcinoma, diabetes, and hypertension could theoretically push the numbers even higher
  • mortality for pulmonary embolism may approach 10%
  • reference - Use of the low-molecular-weight heparin reviparin to prevent deep-vein thrombosis after leg injury requiring immobilization
• DVT in acetabular frx
  • DVT occurs in about 1/3 of patients
    • occurs in 1/5 of patients less than 40 years old
    • occurs in 1/2 of patients over 40 years old
  • risk of pulmonary embolism is about 4-7%
  • in the study by Stannard JP, et al., DVT developed in betwee 13% to 19% depending on the form of DVT prophylaxis
  • increased patient age and the time elapsed from the injury to the surgery were found to be associated with higher rates of thrombosis
  • reference: Mechanical prophylaxis against deep-vein thrombosis after pelvic and acetabular fractures

Hip fracture surgery

• choice of anesthesia
  • in elective hip surgery there is three-fold decrease in thromboembolic complications from the use of regional anesthesia and graded compression stockings
  • reference - Prevention of thromboembolism following elective hip surgery. The value of regional anesthesia and graded compression stockings.
• The thromboprophylactic effect of a low-molecular-weight heparin (Fragmin) in hip fracture surgery. A placebo-controlled study.
• A prospective double-blind trial of a low molecular weight heparin once daily compared with conventional low-dose heparin three times daily to prevent pulmonary embolism and venous thrombosis in patients with hip fracture.
• Low-dose heparin for prevention of venous thromboembolism in total hip arthroplasty and surgical repair of hip fractures.
• Autopsy-verified major pulmonary embolism after hip fracture.
• Efficacy and safety of rivaroxaban versus low-molecular-weight heparin therapy in patients with lower limb fractures.
• Compression ultrasonography for the detection of deep venous thrombosis in patients who have a fracture of the hip. A prospective study.
• Low-molecular-weight heparinoid compared with warfarin for prophylaxis of deep-vein thrombosis in patients who are operated on for fracture of the hip. A prospective, randomized trial.
• Dose relation in the prevention of proximal vein thrombosis with a low molecular weight heparin (tinzaparin) in elective hip arthroplasty.
• Aspirin prophylaxis and surveillance of pulmonary embolism and deep vein thrombosis in total hip arthroplasty.
• Prevention of fatal pulmonary embolism in patients with fractures of the neck of the femur.

Arthroscopy

• reference - Incidence of symptomatic venous thromboembolism after elective knee arthroscopy

  Metastatic Disease:

•  Thromboembolism After Intramedullary Nailing for Metastatic Bone Lesions