DVT Risk Reduction - TKA : Wheeless' Textbook of Orthopaedics

Specific agents

aspirin

heparin agents: (see low molecular wt agents)
- in TKA, 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:
      - 59 (34%) had distal deep-vein thrombosis
      - 20 (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

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
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

reference - Pneumatic sequential-compression boots compared with aspirin prophylaxis of deep-vein thrombosis after total knee arthroplasty.

Vena cava filter

reference - 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

See also - TKR menu

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?

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.