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DVT Risk Reduction – THA

When should prophylaxis 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
    • reference - 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

Prophylactic Agents

  • rivaroxaban (Xarelto)
    • highly selective direct factor Xa inhibitor with oral bioavailability and rapid onset of action
    • availability – 10 mg, 15 mg, and 20 mg tablets
    • indications (non-comprehensive)
      • prophylaxis of deep vein thrombosis (DVT) in adults undergoing hip and knee replacement
      • treatment of patients with DVT and pulmonary embolism (PE)
      • long-term treatment to prevent recurrence of DVT and PE
    • references

Compressive devices

Vena cava filter


  • 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

See also - Total Hip Replacement Menu

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.

Potent anticoagulants are associated with a higher all-cause mortality rate after hip and knee arthroplasty.

Cost-effectiveness impact of rivaroxaban versus new and existing prophylaxis for the prevention of venous thromboembolism after total hip or knee replacement surgery in France, Italy and Spain.

Incidence of neuraxial haematoma after total hip or knee surgery: RECORD programme (rivaroxaban vs. enoxaparin).

Elective hip and knee arthroplasty and the effect of rivaroxaban and enoxaparin thromboprophylaxis on wound healing.

The effects of rivaroxaban on the complications of surgery after total hip or knee replacement: results from the RECORD programme.

Concomitant use of medication with antiplatelet effects in patients receiving either rivaroxaban or enoxaparin after total hip or knee arthroplasty.

Oral rivaroxaban for the prevention of symptomatic venous thromboembolism after elective hip and knee replacement.

Prevention of venous thromboembolic disease after total hip and knee arthroplasty.

Complication rates after hip or knee arthroplasty in morbidly obese patients.

Comparative safety and efficacy of antithrombotics in the management of venous thromboembolism after knee or hip replacement surgery: focus on rivaroxaban.

The efficacy and safety of rivaroxaban for venous thromboembolism prophylaxis after total hip and total knee arthroplasty.