Skip to main content
SpringerLink
Log in

Blood Loss in Cemented THA is not Reduced with Postoperative Versus Preoperative Start of Thromboprophylaxis

  • Clinical Research
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Thrombin formation commences perioperatively in orthopaedic surgery and therefore some surgeons prefer preoperative initiation of pharmacologic thromboprophylaxis. However, because of the potential for increased surgical bleeding, the postoperative initiation of thromboprophylaxis has been advocated to reduce blood loss, need for transfusion, and bleeding complications. Trials on timing of thromboprophylaxis have been designed primarily to detect thrombotic events, and it has been difficult to interpret the magnitude of blood loss and bleeding events owing to lack of information for bleeding volume and underpowered bleeding end points.

Questions/purposes

We therefore asked whether there are differences in blood loss, transfusion requirements, and other postoperative clinical complications with preoperative versus postoperative start of thromboprophylaxis with dalteparin.

Methods

In a double-blind, randomized controlled trial, 80 patients undergoing primary cemented THA were allocated to dalteparin injections starting 12 hours before or 6 hours after surgery. Blood loss was measured by weighing sponges and drapes, volume in suction drains during surgery, and wound drains until removal 24 hours postoperatively. Hemoglobin and hematocrit were recorded at predefined times during and after surgery.

Results

We found no differences in blood loss (1081 mL ± 424 mL versus 1023 mL ± 238 mL), bleeding-related events (10% versus 17%), or number of patients who had transfusions (12 versus five) with preoperative and postoperative thromboprophylaxis, respectively. Other complications were few in both groups.

Conclusions

Our data suggest blood loss is similar with preoperative and postoperative initiation of dalteparin thromboprophylaxis, but indicate a trend toward fewer transfusion requirements which might favor postoperative start of thromboprophylaxis.

Level of Evidence

Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Barr PJ, Donnelly M, Cardwell C, Alam SS, Morris K, Parker M, Bailie KE. Drivers of transfusion decision making and quality of the evidence in orthopedic surgery: a systematic review of the literature. Transfus Med Rev. 2011;25:304–316.

    Article  PubMed  Google Scholar 

  2. Bierbaum BE, Callaghan JJ, Galante JO, Rubash HE, Tooms RE, Welch RB. An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint Surg Am. 1999;81:2–10.

    PubMed  CAS  Google Scholar 

  3. Borgen PO, Dahl OE, Reikeras O. Preoperative versus postoperative initiation of dalteparin thromboprophylaxis in THA. Hip Int. 2010;20:301–307.

    PubMed  Google Scholar 

  4. Carson JL, Duff A, Poses RM, Berlin JA, Spence RK, Trout R, Noveck H, Strom BL. Effect of anaemia and cardiovascular disease on surgical mortality and morbidity. Lancet. 1996;348:1055–1060.

    Article  PubMed  CAS  Google Scholar 

  5. Colwell CW Jr, Chelly JE, Murkin JM, Stevens D, O`Keefe TJ, Hall R, Parvizi J. Randomized study of aprotinin effect on transfusions and blood loss in primary THA. Clin Orthop Relat Res. 2007;465:189–195.

    PubMed  Google Scholar 

  6. Dahl OE, Ogren M, Agnelli G, Eriksson BI, Cohen AT, Mouret P, Rosencher N, Bylock A, Panfilov S, Andersson M. Assessment of bleeding after concomitant administration of antiplatelet and anticoagulant agents in lower limb arthroplasty. Pathophysiol Haemost Thromb. 2006;35:428–434.

    Article  PubMed  CAS  Google Scholar 

  7. Dahl OE, Quinlan DJ, Bergqvist D, Eikelboom JW. A critical appraisal of bleeding events reported in venous thromboembolism prevention trials of patients undergoing hip and knee arthroplasty. J Thromb Haemost. 2010;8:1966–1975.

    Article  PubMed  CAS  Google Scholar 

  8. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–213.

    Article  PubMed  Google Scholar 

  9. Francis CW, Pellegrini VD Jr, Totterman S, Boyd AD Jr, Marder VJ, Liebert KM, Stulberg BN, Ayers DC, Rosenberg A, Kessler C, Johanson NA. Prevention of deep-vein thrombosis after total hip arthroplasty: comparison of warfarin and dalteparin. J Bone Joint Surg Am. 1997;79:1365–1372.

    PubMed  CAS  Google Scholar 

  10. Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CW; American College of Chest Physicians. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. 8th ed. Chest. 2008;133(6 suppl):381S–453S.

    Google Scholar 

  11. Graafsma YP, Prins MH, Lensing AW, de Haan RJ, Huisman MV, Buller HR. Bleeding classification in clinical trials: observer variability and clinical relevance. Thromb Haemost. 1997;78:1189–1192.

    PubMed  CAS  Google Scholar 

  12. Hull RD, Liang J, Brant R. Pooled analysis of trials may, in the presence of heterogeneity inadvertently lead to fragile conclusions due to the importance of clinically relevant variables being either hidden or lost when the findings are pooled. Thromb Res. 2010;126:164–165.

    Article  PubMed  CAS  Google Scholar 

  13. Hull RD, Pineo GF, Francis C, Bergqvist D, Fellenius C, Soderberg K, Holmqvist A, Mant M, Dear R, Baylis B, Mah A, Brant R. Low-molecular-weight heparin prophylaxis using dalteparin in close proximity to surgery vs warfarin in hip arthroplasty patients: a double-blind, randomized comparison. The North American Fragmin Trial Investigators. Arch Intern Med. 2000;160:2199–2207.

    Article  PubMed  CAS  Google Scholar 

  14. Hull RD, Yusen RD, Bergqvist D. State-of-the-art review: assessing the safety profiles of new anticoagulants for major orthopedic surgery thromboprophylaxis. Clin Appl Thromb Hemost. 2009;15:377–388.

    Article  PubMed  CAS  Google Scholar 

  15. Johansson T, Pettersson LG, Lisander B. Tranexamic acid in total hip arthroplasty saves blood and money: a randomized, double-blind study in 100 patients. Acta Orthop. 2005;76:314–319.

    PubMed  Google Scholar 

  16. Kakkar AK, Brenner B, Dahl OE, Eriksson BI, Mouret P, Muntz J, Soglian AG, Pap AF, Misselwitz F, Haas S; RECORD2 Investigators. 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;372:31–39.

    Article  PubMed  CAS  Google Scholar 

  17. Kakkar VV, Howe CT, Flanc C, Clarke MB. Natural history of postoperative deep-vein thrombosis. Lancet. 1969;2:230–232.

    Article  PubMed  CAS  Google Scholar 

  18. Lachiewicz PF. Comparison of ACCP and AAOS guidelines for VTE prophylaxis after total hip and total knee arthroplasty. Orthopedics. 2009;32(12 suppl):74–78.

    Article  PubMed  Google Scholar 

  19. Lemaire R. Strategies for blood management in orthopaedic and trauma surgery. J Bone Joint Surg Br. 2008;90:1128–1136.

    Article  PubMed  CAS  Google Scholar 

  20. Liu X, Zhang X, Chen Y, Wang Q, Jiang Y, Zeng B. Hidden blood loss after total hip arthroplasty. J Arthroplasty. 2011;26:1100–1105.

    Article  PubMed  Google Scholar 

  21. Novicoff WM, Brown TE, Cui Q, Mihalko WM, Slone HS, Saleh KJ. Mandated venous thromboembolism prophylaxis: possible adverse outcomes. J Arthroplasty. 2008;23(6 suppl 1):15–19.

    Article  PubMed  Google Scholar 

  22. Patel VP, Walsh M, Sehgal B, Preston C, DeWal H, Di Cesare PE. Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty. J Bone Joint Surg Am. 2007;89:33–38.

    Article  PubMed  Google Scholar 

  23. Planes A, Vochelle N, Mazas F, Mansat C, Zucman J, Landais A, Pascariello JC, Weill D, Butel J. Prevention of postoperative venous thrombosis: a randomized trial comparing unfractionated heparin with low molecular weight heparin in patients undergoing total hip replacement. Thromb Haemost. 1988;60:407–410.

    PubMed  CAS  Google Scholar 

  24. Raskob GE, Hirsh J. Controversies in timing of the first dose of anticoagulant prophylaxis against venous thromboembolism after major orthopedic surgery. Chest. 2003;124(6 suppl):379S–385S.

    Article  PubMed  Google Scholar 

  25. Salido JA, Marin LA, Gomez LA, Zorrilla P, Martinez C. Preoperative hemoglobin levels and the need for transfusion after prosthetic hip and knee surgery: analysis of predictive factors. J Bone Joint Surg Am. 2002;84:216–220.

    Article  PubMed  Google Scholar 

  26. Sehat KR, Evans RL, Newman JH. Hidden blood loss following hip and knee arthroplasty: correct management of blood loss should take hidden loss into account. J Bone Joint Surg Br. 2004;86:561–565.

    PubMed  CAS  Google Scholar 

  27. Sharrock NE, Go G, Harpel PC, Ranawat CS, Sculco TP, Salvati EA. The John Charnley Award: thrombogenesis during total hip arthroplasty. Clin Orthop Relat Res. 1995;319:16–27.

    PubMed  Google Scholar 

  28. Strebel N, Prins M, Agnelli G, Buller HR. Preoperative or postoperative start of prophylaxis for venous thromboembolism with low-molecular-weight heparin in elective hip surgery? Arch Intern Med. 2002;162:1451–1456.

    Article  PubMed  CAS  Google Scholar 

  29. Walsh M, Preston C, Bong M, Patel V, Di Cesare PE. Relative risk factors for requirement of blood transfusion after total hip arthroplasty. J Arthroplasty. 2007;22:1162–1167.

    Article  PubMed  Google Scholar 

  30. Warwick D, Bannister GC, Glew D, Mitchelmore A, Thornton M, Peters TJ, Brookes S. Perioperative low-molecular-weight heparin: is it effective and safe. J Bone Joint Surg Br. 1995;77:715–719.

    PubMed  CAS  Google Scholar 

Download references

Acknowledgments

We thank Nina Bøhler, study nurse, for valuable help in preparing the injections and conducting the block randomization in this controlled study.

Author information

Authors and Affiliations

  1. Martina Hansens Hospital, P.O. Box 23, 1306, Baerum Postterminal, Norway

    Pål O. Borgen MD

  2. Department of Orthopaedics, Innlandet Hospital Trust, Lillehammer, Norway

    Ola E. Dahl MD, PhD

  3. Thrombosis Research Institute, London, UK

    Ola E. Dahl MD, PhD

  4. Department of Orthopaedics, Oslo University Clinic, Rikshospitalet, Oslo, Norway

    Olav Reikerås MD, PhD

Authors
  1. Pål O. Borgen MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ola E. Dahl MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Olav Reikerås MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Pål O. Borgen MD.

Additional information

Each author certifies that he, or a member of his immediate family, has no commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in the connection with this submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

Each author certifies that his institution approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.

This study was performed at Martina Hansens Hospital, Baerum Postterminal, Norway.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOC 68 kb)

About this article

Cite this article

Borgen, P.O., Dahl, O.E. & Reikerås, O. Blood Loss in Cemented THA is not Reduced with Postoperative Versus Preoperative Start of Thromboprophylaxis. Clin Orthop Relat Res 470, 2591–2598 (2012). https://doi.org/10.1007/s11999-012-2320-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11999-012-2320-9

Keywords

Search

Navigation