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    PRACTICE PEARLS: DVT Prophylaxis in Total Joint Arthroplasty

    Deep vein thrombosis (DVT) is one of the most common postoperative complications following total joint arthroplasty (TJA), and various pharmacologic and mechanical options are available to prevent its occurrence.

    Raymond H. Kim, MD, from Colorado Joint Replacement in Denver, discusswed the current status of DVT prophylaxis at the ICJR South/RLO Spring Hip & Knee Course. Ultimately, the goal is to prevent fatal pulmonary embolism (PE) while balancing the morbidities, such as bleeding, associated with prophylactic regimens, Dr. Kim said.

    PE can occur in 1.5% to 10% of all surgeries, with fatal PE in up to 1.7% of procedures [1]. Major orthopaedic surgery in particular is a risk factor, as is a history of DVT, a hypercoagulable state, cancer, older age, and obesity. The current reported rates of DVT/PE after TJA are 15% to 25% for total hip arthroplasty and 35% to 50% after total knee arthroplasty. The rate of fatal PE for all treatment regimens used in TJA is 0.1%.

    Dr. Kim reviewed the pharmacologic and mechanical prophylaxis currently in use.

    Pharmacologic Prophylaxis

    The ideal pharmacologic agent should have a high efficacy-to-safety index and a predictable dose response. It should also be convenient to administer, require no monitoring, and have no side effects or drug interactions. In addition, it should be inexpensive and reversible with a safe antidote.

    Does this agent exist yet? Dr. Kim reviewed the evidence to date.

    Warfarin

    The benefits of warfarin include oral administration, low cost, and better-looking wounds [2]. However, the need for monitoring, the narrow therapeutic range, and multiple food and drug interactions are limitations to consider. [3,4]

    Low-Molecular-Weight Heparin (LMWH)

    Use of LMWH does not require coagulation monitoring and has been shown to successfully reduce the incidence of DVT and PE. But LMWH has also been shown to increase the risk for major bleeding. [5]

    Aspirin

    A study by Lotke [6] concluded that the rate of fatal PE using aspirin is as low as with any other anticoagulant.

    Factor Xa Inhibitors

    These drugs have an efficacy similar to LMWH, but studies have shown an increased risk for bleeding. In addition, Factor Xa Inhibitors are contraindicated in patients with renal insufficiency.

    Newer oral anticoagulants such as oral Factor Xa Inhibitors seem to offer attractive alternatives, [7] Dr. Kim said. These agents require no routine monitoring. They have a rapid onset and predictable effect with low drug and food interactions.

    Multiple studies have shown that oral rivaroxaban (Xarelto) reduces the incidence of DVT; however, studies have also shown an increased risk for major bleeding and wound complications. [8,9,10,11,12]

    Mechanical Prophylaxis

    Mechanical DVT prophylaxis, such as compression stockings, pneumatic compression devices, and foot pumps, have been shown to reduce DVT in joint replacement patients. [13,14,15]

    Current Recommendations

    The 2012 guidelilnes from American College of Chest Physicians (ACCP) recommend pharmacologic prophylaxis for a minimum of 14 days.

    The 2007 AAOS guidelines examined symptomatic PE as an outcome measure and found no difference among the available interventions in rates of PE, fatal PE, or total death following joint replacement surgery. The consensus is a recommendation for the use of regional anesthesia, mechanical prophylaxis, rapid mobilization, and patient education to prevent DVT/PE.

    These guidelines also recommend preoperative evaluation for PE and bleeding and advise surgeons to consider the risk/benefit ratio when deciding on the type of prophylaxis.

    For standard risk of PE and major bleeding, the recommendations include aspirin, LMWH, pentasaccharide, and warfarin (INR ≤ 2).

    In 2011, the AAOS guidelines were updated to include a “Strong Recommendation” against routine postoperative ultrasound screening after hip and knee arthroplasty.

    “Moderate Recommendations” include:

    • Use of a pharmacologic agent and/or mechanical compression device
    • Discontinuation of antiplatelet treatment prior to surgery
    • Use of neuraxial anesthesia

    “Consensus Recommendations” advise evaluating patients for increased risk for bleeding. In patients with a history of DVT, both pharmacologic and mechanical prophylaxis should be used. In patients with a history of bleeding disorder, only mechanical prophylaxis should be used. And finally, early mobilization is recommended.

    The recommendations from the Surgical Care Improvement Project (SCIP) include ordering some form of DVT prophylaxis, which must be administered within 24 hours after surgery. Several pharmacologic agents are recommended, including aspirin, without needing documentation of increased bleeding risk.

    Summary

    Dr. Kim said that each new pharmacologic prophylaxis agent introduced has resulted in a progressively lower rate of DVT. However, the overall incidence of fatal PE has not changed.

    As such, the goal of prophylactic treatment remains to reduce the risk of fatal PE while minimizing the risk of complications associated with treatment.

    Click the image above to watch Dr. Kim’s presentation from the ICJR South/RLO Course.

    References

    1. Geerts WH, Pineo GF, Heit JA et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004 Sep;126(3 Suppl):338S-400S.
    2. Enneking FK, Benzon H. Oral anticoagulants and regional anesthesia: a perspective. Reg Anesth Pain Med. 1998 Nov-Dec;23(6 Suppl 2):140-5.
    3. Geerts WH, Heit JA, Clagett GP et al. Prevention of venous thromboembolism. Chest. 2001 Jan;119(1 Suppl):132S-175S.
    4. Wittkowsky AK, Devine EB. Frequency and causes of overanticoagulation and underanticoagulation in patients treated with warfarin. Pharmacotherapy. 2004 Oct;24(10):1311-6.
    5. Brookenthal KR, Freedman KB, Lotke PA, Fitzgerald RH, Lonner JH. A meta-analysis of thromboembolic prophylaxis in total knee arthroplasty. J Arthroplasty. 2001 Apr;16(3):293-300.
    6. Lotke PA. The role of aspirin for thromboembolic disease in total joint arthroplasty. Am J Knee Surg. 1999 Winter;12(1):61-3.
    7. Eikelboom JW, Weitz JI. New anticoagulants. Circulation. 2010 Apr 6;121(13):1523-32
    8. Eriksson BI, Borris LC, Friedman RJ et al. Rivaroxaban versus enoxaparin for thromboprophylaxis after hip arthroplasty. N Engl J Med. 2008 Jun 26;358(26):2765-75.
    9. Kakkar AK, Brenner B, Dahl OE et al. Extended duration rivaroxaban versus short-term enoxaparin for the prevention of venous thromboembolism after total hip arthroplasty: a double-blind, randomised controlled trial. Lancet. 2008 Jul 5;372(9632):31-9.
    10. Lassen MR, Ageno W, Borris LC et al. Rivaroxaban versus enoxaparin for thromboprophylaxis after total knee arthroplasty. N Engl J Med. 2008 Jun 26;358(26):2776-86.
    11. Jensen CD, Steval A, Partington PF, Reed MR, Muller SD. Return to theatre following total hip and knee replacement, before and after the introduction of rivaroxaban: a retrospective cohort study. J Bone Joint Surg Br. 2011 Jan;93(1):91-5.
    12. Jameson SS, Rymaszewska M, Hui AC, James P, Serrano-Pedraza I, Muller SD. Wound complications following rivaroxaban administration: a multicenter comparison with low-molecular-weight heparins for thromboprophylaxis in lower limb arthroplasty. J Bone Joint Surg Am. 2012 Sep 5;94(17):1554-8.
    13. Barnes RW, Brand RA, Clarke W, Hartley N, Hoak JC. Efficacy of Graded-compression Antiembolism Stockings in Patients Undergoing Total Hip Arthroplasty. CORR 1978, 132;p61-67.
    14. Haas SB, Insall JN, Scuderi GR, Windsor RE, Ghelman B. Pneumatic sequential-compression boots compared with aspirin prophylaxis of deep-vein thrombosis after total knee arthroplasty. J Bone Joint Surg Am. 1990 Jan;72(1):27-31.
    15. Westrich GH, Sculco TP. Prophylaxis against deep venous thrombosis after total knee arthroplasty. Pneumatic plantar compression and aspirin compared with aspirin alone. J Bone Joint Surg Am. 1996;78:826–834.