An Update on DVT Prophylaxis for Total Joint Arthroplasty Patients
Orthopaedic surgeons have known since the earliest days of arthroplasty that patients undergoing elective joint replacement surgery are at risk for deep vein thrombosis (DVT). Dr. John Charnley, the father of total hip arthroplasty, reported a 2.3% rate of fatal pulmonary embolism (PE) in his patients who had not received DVT prophylaxis, compared with 0.3% in those who had. 
Today, unfortunately, DVT and PE remain an issue for total knee and total hip arthroplasty patients: The readmission rate for DVT and PE after joint replacement surgery is between 5% and 14%, adding to patient morbidity and the cost of the episode of care. 
Balanced against the need for prophylaxis to prevent a catastrophic complication is the understanding that a too-aggressive protocol for DVT prophylaxis will put the joint replacement patient at risk for bleeding, hematoma, and wound issues – which could lead to a perioprosthetic joint infection.
The answer, said Michael J. Taunton, MD, is a patient-specific approach to DVT prophylaxis that balances safety and efficacy, taking into account patient and surgical factors such as the length of the procedure, the use of a tourniquet, and the surgical approach. What’s more, he said in a presentation at the ICJR South Hip & Knee Course, orthopaedic surgeons must take the lead in determining what’s best for their joint replacement patients, working in partnership with their medical colleagues.
Dr. Taunton discussed the 2011 guidelines on preventing venous thromboembolism from the American Academy of Orthopaedic Surgeons,  noting that most of the recommendations are based on consensus due to the lack of orthopaedic literature on optimal strategies for DVT prophylaxis. In general, the AAOS guidelines advocate:
- Chemical and/or mechanical prophylaxis for normal-risk patients
- Chemical and mechanical prophylaxis for high-risk patients
- Mechanical prophylaxis for patients with bleeding disorders
Dr. Taunton said that the PEPPER study (Comparative Effectiveness of Pulmonary Embolism Prevention After Hip and Knee Replacement) will likely provide answers on chemical prophylaxis.  This multicenter study, which includes his institution, Mayo Clinic in Rochester, Minnesota, involves 25,000 patients who are randomized to receive 1 of 3 interventions:
- Aspirin, 81 mg PO twice a day
- Warfarin based on an INR between 1.7 and 2.2 (target 2.0)
- Rivaroxaban, 10 mg once a day
It will be several years before orthopaedic surgeons have any answers, though: This ongoing study is scheduled for completion in 2021.
In the meantime, Dr. Taunton follows this protocol for DVT prophylaxis:
- Stay on clopidogrel (Plavix) and aspirin (81 mg) if prescribed preoperatively
- Mechanical prophylaxis: early mobilization (walk on POD0), foot pumping, sequential compression device
- Chemical prophylaxis: 325 mg of aspirin twice a day for 35 days for most patients; 81 mg of aspirin twice a day for 35 days for older patients and patients with a history of gastrointestinal issues
- Low-molecular-weight heparin for 5 days preoperatively and 2 days postoperatively if bridging; skip low-molecular-weight heparin if not bridging
- Mechanical prophylaxis: early mobilization (walk on POD0), foot sequential compression device
- Chemical prophylaxis: 10 mg daily of rivaroxaban for 35 days
Click the image above to watch Dr. Taunton’s presentation.
Dr. Taunton has no disclosures relevant to this article.
- Johnson R, Green JR, Charnley J. Pulmonary embolism and its prophylaxis following the Charnley total hip replacement. Clin Orthop Relat Res. 1977;(127):123-32.
- Spyropoulous AC, Lin J. Direct medical costs of venous thromboembolism and subsequent hospital readmission rates: an administrative claims analysis from 30 managed care organizations. J Manag Care Pharm. 2007 Jul-Aug;13(6):475-86.
- Mont MA, Jacobs JJ, Boggio LN, et al. Preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Am Acad Orthop Surg. 2011 Dec;19(12):768-76.
- Comparative Effectiveness of Pulmonary Embolism Prevention After Hip and Knee Replacement (PEPPER). ClinicalTrials.gov identifier NCT02810704. Accessed July 24, 2018.