What’s a Typical DVT Prophylaxis Protocol for TJA Patients?
Dr. Anna Cohen-Rosenblum answers ICJR’s questions about protocols for managing total joint arthroplasty patients at low and high risk for postoperative deep vein thrombosis/pulmonary embolism.
ICJR: When considering prophylaxis for deep vein thrombosis (DVT) in patients who have undergone primary total joint arthroplasty (TJA), what criteria do you use to risk-stratify into “low risk” and “high risk” patients?
Anna Cohen-Rosenblum, MD, MSc: I consider high-risk patients to be those with:
- A personal or immediate family history of DVT/pulmonary embolism (PE)
- A personal history of hypercoagulability disorder
- Any active malignancy
I make sure to ask all new patients in clinic about these risk factors. If they do have a personal history of DVT/PE, I try to determine the circumstances behind it – was it provoked or unprovoked, how was it treated, and so on – to help guide treatment.
I have recently added COVID-19 infection within 3 months to the high-risk category following discussions with hematology colleagues, even though there is not a huge amount of data available regarding the effect of COVID-19 infection on clotting risk.
All other patients I would consider to be at low risk for DVT/PE.
ICJR: What is your protocol for low-risk primary TJA patients? Is it the same for primary hip and knee arthroplasty patients?
Dr. Cohen-Rosenblum: Low-risk primary total hip and knee patients are prescribed 81 mg of aspirin twice a day for 6 weeks total. I also send everyone home with a prescription for a proton pump inhibitor to decrease the risk of gastrointestinal bleeding, and I limit postoperative non-steroidal anti-inflammatory drugs to celecoxib, which is a selective COX-2 inhibitor with decreased risk of gastrointestinal side effects.
ICJR: What is your protocol for high-risk primary TJA patients, including the drugs, dose, and duration? Is it the same for primary hip and knee arthroplasty patients?
Dr. Cohen-Rosenblum: I closely collaborate with hematology colleagues for hip and knee arthroplasty patients that I have determined to be at high risk for DVT/PE. I frequently send these high-risk patients to hematology for a preoperative consult and recommendations for postoperative DVT prophylaxis.
In general, relatively straightforward patients with a strong family history of DVT/PE and/or a personal history of provoked DVT are prescribed 2.5 mg of apixaban twice a day for 35 days.
Individuals with more complex histories of coagulopathy will have more complicated regimens. If patients are on preoperative anticoagulation, I generally restart their home dose on POD1 in the morning; I do not add anything else. I closely collaborate with hematology colleagues on patients who require bridging anticoagulation – for example, if they are on warfarin preoperatively and need to have enoxaparin or heparin on board while the warfarin is stopped in preparation for their elective TJA surgery.
In rare cases, I collaborate with vascular surgery colleagues for preoperative insertion and postoperative removal of retrievable inferior vena cava filters in patients who have a high risk of postoperative bleeding with bridging anticoagulation.
Our agreed-upon protocol for patients with a COVID-19 infection within 3 months and no other personal or family history of DVT/PE is 4 weeks of subcutaneous enoxaparin, 40 mg daily, followed by 2 weeks of aspirin, 81 mg twice a day. This is not based on any published evidence but takes into consideration the possible increased risk of coagulopathy after COVID-19 infection.
ICJR: What about for revision TJA patients: Is the protocol the same as for primary procedures?
Dr. Cohen-Rosenblum: My protocol for revision patients is the same as for primary procedures.
ICJR: Do you ever recommend the use of mechanical prophylaxis measures, such as the graduated compression stockings, intermittent pneumatic compression, or venous foot pumps, for primary or revision TJA patients?
Dr. Cohen-Rosenblum: I always use intermittent pneumatic compression devices while patients are in the hospital postoperatively and recommend compression stockings for both primary and revision TJA. Anecdotally, I have found that patient adherence to wearing compression stockings is not high.
Anna Cohen-Rosenblum, MD, MSc, is an Assistant Professor in the Department of Orthopaedic Surgery, LSU Health, New Orleans, Louisiana.
Disclosures: Dr. Cohen-Rosenblum has no disclosures relevant to this article.