Current Reviews in Musculoskeletal Medicine

, Volume 7, Issue 2, pp 108–116

Venous Thromboembolism (VTE) Prophylaxis for Hip and Knee Arthroplasty: Changing Trends

  • Nicolaas C. Budhiparama
  • Matthew P. Abdel
  • Nadia N. Ifran
  • Sébastien Parratte
TKA Symposium (P Sancheti, Section Editor)

Abstract

Venous thromboembolism (VTE) has been identified as an immediate threat to patients undergoing major orthopedic procedures such as total hip arthroplasty (THA) and total knee arthroplasty (TKA). Given the known dangers of VTE, arthroplasty surgeons are sensitive to the need for VTE thromboprophylaxis. However, the modalities of thromboprophylaxis used to minimize the risks to patients have been variable. Clinical practice guidelines have been published by several professional organizations, while some hospitals have established their own protocols. The 2 most popular guidelines are those published by the Academy of Orthopaedic Surgeons (AAOS) and American College of Chest Physicians (ACCP), both from North America. Prior to 2012, these recommendations varied depending on underlying definitions, methodology, and goals of the 2 groups. For the first time, both groups have similar recommendations that focus on minimizing symptomatic VTE and bleeding complications. The key to determining the appropriate chemoprophylaxis for patients is to balance efficacy of a prophylactic agent, while being safe in regards to bleeding complications. However, a multimodal approach that focuses on early postoperative mobilization and the use of mechanical prophylaxis, in addition to chemoprophylaxis, is essential.

Keywords

Venous thromboembolism (VTE) Deep vein thrombosis (DVT) Pulmonary embolism (PE) Thromboprophylaxis Total joint arthroplasty Clinical guidelines Mechanical prophylaxis Chemical prophylaxis Hip Knee Prophylaxis 

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Ciccone II WJ, Fox PS, Neumyer M, Rubens D, Parrish WM, Pellegrini Jr VD. Ultrasound surveillance for asymptomatic deep venous thrombosis after total joint replacement. J Bone Joint Surg Am. 1998;80:1167–74.PubMedGoogle Scholar
  2. 2.
    Selby R, Borah BJ, McDonald HP, Henk HJ, Crowther M, Wells PS. Impact of thrombo-prophylaxis guidelines on clinical outcomes following total hip and total knee replacement. Thromb Res. 2012;130(2):166–72.Google Scholar
  3. 3.
    Parvizi J, Jacovides CL, Bican O, et al. Is deep vein thrombosis a good proxy for pulmonary embolus? J Arthroplasty. 2010;25:138–44.PubMedCrossRefGoogle Scholar
  4. 4.
    Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(Suppl):338S–400.PubMedCrossRefGoogle Scholar
  5. 5.
    Galat DD, McGovern SC, Larson DR, et al. Surgical treatment of early wound complications following primary total knee arthroplasty. J Bone Joint Surg Am. 2009;91-A:48–54.CrossRefGoogle Scholar
  6. 6.
    Keeney JA, Clohisy JC, Curry MC, Maloney WJ. Efficacy of combined modality prophylaxis including short-duration warfarin to prevent venous thromboembolism after total hip arthroplasty. J Arthroplasty. 2006;21:469–75.PubMedCrossRefGoogle Scholar
  7. 7.
    Novicoff WM, Brown TE, Cui Q, et al. Mandated venous thromboembolism prophylaxis: possible adverse outcomes. J Arthroplasty. 2008;23:15–9.PubMedCrossRefGoogle Scholar
  8. 8.
    Bozic KJ, Vail TP, Pekow PS, et al. Does aspirin have a role in venous thromboembolism prophylaxis in total knee arthroplasty patients? J Arthroplasty. 2010;25:1053–60.PubMedCrossRefGoogle Scholar
  9. 9.
    Callaghan JJ, Warth LC, Hoballah JJ, Liu SS, Wells CW. Evaluation of deep venous thrombosis prophylaxis in low-risk patients undergoing total knee arthroplasty. J Arthroplasty. 2008;23:20–4.PubMedCrossRefGoogle Scholar
  10. 10.
    Lotke PA, Lonner JH. The benefit of aspirin chemoprophylaxis for thromboembolism after total knee arthroplasty. Clin Orthop Relat Res. 2006;452:175–80.PubMedCrossRefGoogle Scholar
  11. 11.
    Norris SL, Holmer HK, Burda BU, Ogden LA, Fu R. Conflict of interest policies for organizations producing a large number of clinical practice guidelines. PLoS ONE. 2012;7:37413.CrossRefGoogle Scholar
  12. 12.•
    Mont MA, Jacobs JJ, Boggio LN, Bozic KJ, Valle CJD, Goodman SB, et al. AAOS clinical practice guideline: preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Am Acad Orthop Surg. 2011;19:777–8. This article shows the latest thromboprophylaxis clinical guidelines from AAOS.PubMedGoogle Scholar
  13. 13.•
    Falck-Ytter Y, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S, et al. American College of Chest Physicians. Prevention of VTE in orthopedic surgery patients: antithrombotic therapy and prevention of thrombosis, 9th ed. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e278S–325S. This article shows the latest thromboprophylaxis clinical guidelines from ACCP. Google Scholar
  14. 14.
    Colwell Jr CW, Froimson MI, Mont MA, et al. Thrombosis prevention after total hip arthroplasty: a prospective, randomized trial comparing a mobile compression device with low-molecular-weight heparin. J Bone Joint Surg Am. 2010;92-A:527–35.Google Scholar
  15. 15.
    Jameson SS, Charman SC, Gregg PJ, Reed MR, van der Meulen JH. The effect of aspirin and low-molecular-weight heparin on venous thromboembolism after hip replacement: a non-randomized comparison from information in the National Joint Registry. J Bone Joint Surg (Br). 2011;93-B:1465–70.CrossRefGoogle Scholar
  16. 16.
    Eriksson BI, Kakkar AK, Turpie AG, et al. Oral rivaroxaban for the prevention of symptomatic venous thromboembolism after elective hip and knee replacement. J Bone Joint Surg (Br). 2009;91-B:636–44.CrossRefGoogle Scholar
  17. 17.
    Raskob GE, Gallus AS, Pineo GF, et al. Apixaban vs enoxaparin for thromboprophylaxis after hip or knee replacement: pooled analysis of major venous thromboembolism and bleeding in 8464 patients from the ADVANCE-2 and ADVANCE-3 trials. J Bone Joint Surg (Br). 2012;94-B:257–64.CrossRefGoogle Scholar
  18. 18.
    Warwick D. Prevention of venous thromboembolism in total knee and hip replacement. Circulation. 2012;125:2151–5.PubMedCrossRefGoogle Scholar
  19. 19.
    Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial. Lancet. 2000;355:1295–302.Google Scholar
  20. 20.
    Vulcano E, Gessel M, Esposito A, Ma Y, Memtsoudis S, Valle AGD. Aspirin for elective hip and knee arthroplasty: a multimodal thromboprophylaxis protocol. Int Orthop. 2012;36:1995–2002.PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    Nikolaou VS, Desy NM, Bergeron SG, Antoniou J. Total knee replacement and chemical thromboprophylaxis: current evidence. Curr Vasc Pharmacol. 2011;9:33–41.PubMedCrossRefGoogle Scholar
  22. 22.
    Leyvraz PF, Bachmann F, Hoek J, Buller HR, Postel M, Samama M, et al. Prevention of deep vein thrombosis after hip replacement: randomized comparison between unfractionated heparin and low molecular weight heparin. BMJ. 1991;303:543–8.PubMedCentralPubMedCrossRefGoogle Scholar
  23. 23.
    Merli GJ, Groce JB. Pharmacological and clinical differences between low-molecular-weight-heparins. Implications for prescribing practice and therapeutic interchange. Phys Ther. 2010;35:95–105.Google Scholar
  24. 24.•
    Outes GA, Fernandez AIT, Gea LS, Castrillon EV. Dabigatran, rivaroxaban, or apixaban vs enoxaparin for thromboprophylaxis after total hip or knee replacement: systematic review, meta-analysis, and indirect treatment comparison. BMJ. 2012;344:e3675. This article shows that the recent and newer anticoagulants are higher in efficacy but also resulted in higher bleeding risk, although statistically insignificant, when compared with enoxaparin.CrossRefGoogle Scholar
  25. 25.
    Dranitsaris G, Jelincic V, Choe Y. Meta regression analysis to indirectly compare dalteparin to enoxaparin for the prevention of venous thromboembolic events following total hip replacement. Thromb J. 2011;9:3.PubMedCentralPubMedCrossRefGoogle Scholar
  26. 26.
    O’Brien BJ, Anderson DR, Goeree R. Cost-effective of enoxaparin vs warfarin prophylaxis against deep-vein thrombosis after hip replacement. Can Med Assoc J. 1994;15:1083–90.Google Scholar
  27. 27.
    Kirley K, Qato DM, Kornfield R, Stafford RS, Alexander GC. National trends in oral anticoagulants use in the United States, 2007–2011. Circ Cardiovasc Qual Outcomes. 2012;5:615–21.PubMedCentralPubMedCrossRefGoogle Scholar
  28. 28.
    Hull RD, Raskob GE, Pineo G, Rosenbloom D, Evans W, Mallory T, et al. A comparison of subcutaneous low-molecular-weight heparin with warfarin sodium for prophylaxis against deep-vein thrombosis after hip or knee implantation. N Engl J Med. 1993;329:1370–6.PubMedCrossRefGoogle Scholar
  29. 29.
    RD Heparin Arthroplasty Group. RD heparin compared with warfarin for prevention of venous thromboembolic disease following total hip or knee arthroplasty. J Bone Joint Surg Am. 1994;76:1174–85.Google Scholar
  30. 30.
    Leclerc JR, Geerts WH, Desjardins L, Laflamme GH, L’Esperance B, Demers C, et al. Prevention of venous thromboembolism after knee arthroplasty. A randomized, double-blind trial comparing enoxaparin with warfarin. Ann Intern Med. 1996;124:619–26.PubMedCrossRefGoogle Scholar
  31. 31.
    Heit JA, Berkowitz SD, Bona R, Cabanas V, Corson JD, Elliott CG, et al. Efficacy and safety of low molecular weight heparin (ardeparin sodium) compared with warfarin for the prevention of venous thromboembolism after total knee replacement surgery: a double-blind, dose- ranging study. Thromb Haemost. 1997;77:32–8.PubMedGoogle Scholar
  32. 32.
    Fitzgerald Jr RH, Spiro TE, Trowbridge AA, Gardiner Jr GA, Whitsett TL, O’Connell MB, et al. Prevention of venous thrombo-embolic disease following primary total knee arthroplasty. A randomized, multicenter, open-label, parallel-group comparison of enoxaparin and warfarin. J Bone Joint Surg Am. 2001;83:900–6.PubMedGoogle Scholar
  33. 33.
    Bates SM, Weitz JI. New anticoagulants: beyond heparin, low-molecular-weight heparin and warfarin. Br J Pharmacol. 2005;144:1017–28.PubMedCentralPubMedCrossRefGoogle Scholar
  34. 34.
    Fuji T, Fujita S, Ochi T. Fondaparinux prevents venous thromboembolism after joint replacement surgery in Japanese patients. Int Orthop. 2008;32:443–51.PubMedCentralPubMedCrossRefGoogle Scholar
  35. 35.
    Harenberg J, Marx S, Krejczy M, Wehling M. New anticoagulants—promising and failed developments. Br J Pharmacol. 2012;165:363–72.PubMedCentralPubMedCrossRefGoogle Scholar
  36. 36.
    Turpie AG, Bauer KA, Eriksson BI, Lassen MR, PENTATHALON 2000 Study Steering Committee. Postoperative fondaparinux vs postoperative enoxaparin for prevention of venous thromboembolism after elective hip-replacement surgery: a randomized double-blind trial. Lancet. 2002;359:1721–6.PubMedCrossRefGoogle Scholar
  37. 37.
    Bauer KA, Eriksson BI, Lassen MR, Turpie AG, Steering Committee of the Pentasaccharide in Major Knee Surgery Study. Fondaparinux compared with enoxaparin for the prevention of venous thromboembolism after elective major knee surgery. N Engl J Med. 2001;345:1305–10.PubMedCrossRefGoogle Scholar
  38. 38.
    Lassen MR, Ageno W, Borris LC, Lieberman JR, Rosencher N, Bandel TJ, et al. Rivaroxaban vs enoxaparin for thromboprophylaxis after total knee arthroplasty. N Engl J Med. 2008;358:2776–86.PubMedCrossRefGoogle Scholar
  39. 39.
    Turpie AG, Lassen MR, Davidson BL, Bauer KA, Gent M, Kwong LM, et al. Rivaroxaban vs enoxaparin for thromboprophylaxis after total knee arthroplasty (RECORD4): a randomized trial. Lancet. 2009;373:1673–80.PubMedCrossRefGoogle Scholar
  40. 40.
    Eriksson BI, Borris LC, Friedman RJ, Haas S, Huisman MV, Kakkar AK, et al. Rivaroxaban vs enoxaparin for thromboprophylaxis after hip arthroplasty. N Engl J Med. 2008;358:2765–75.PubMedCrossRefGoogle Scholar
  41. 41.
    Kakkar AK, Brenner B, Dahl OE, Eriksson BI, Mouret P, Muntz J, et al. Extended duration rivaroxaban vs short-term enoxaparin for the prevention of venous thromboembolism after total hip arthroplasty: a double-blind, randomized controlled trial. Lancet. 2008;372:31–9.PubMedCrossRefGoogle Scholar
  42. 42.
    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;93:91–5.CrossRefGoogle Scholar
  43. 43.
    Lassen MR, Gent M, Kakkar AK, Eriksson BI, Homering M, Berkowitz SD, et al. The effects of rivaroxaban on the complications of surgery after total hip or knee replacement. J Bone Joint Surg (Br). 2012;94-B:1573–8.CrossRefGoogle Scholar
  44. 44.
    Lassen MR, Raskob GE, Gallus A, Pineo G, Chen D, Portman RJ. Apixaban or enoxaparin for thromboprophylaxis after knee replacement. N Engl J Med. 2009;361:594–604.PubMedCrossRefGoogle Scholar
  45. 45.
    Lassen MR, Raskob GE, Gallus A, Pineo G, Chen D, Hornick P, et al. Apixaban vs enoxaparin for thromboprophylaxis after knee replacement (ADVANCE-2): a randomized double-blind trial. Lancet. 2010;375:807–15.PubMedCrossRefGoogle Scholar
  46. 46.
    Lassen MR, Gallus A, Raskob GE, Pineo G, Chen D, Ramirez LM, et al. Apixaban vs enoxaparin for thromboprophylaxis after hip replacement. N Engl J Med. 2010;363:2487–9.PubMedCrossRefGoogle Scholar
  47. 47.
    Russell RD, Huo MH. Apixaban and rivaroxaban decrease deep vein thrombosis but not other complications after total hip and total knee arthroplasty. J Arthroplasty. 2013;28:1477–81.PubMedCrossRefGoogle Scholar
  48. 48.
    Dahl OE. New oral antithrombotics: focus on dabigatran, an oral, reversible direct thrombin inhibitor for the prevention and treatment of venous and arterial thromboembolic disorders. Vasc Health Risk Manag. 2012;8:45–57.PubMedCentralPubMedGoogle Scholar
  49. 49.
    Eriksson BI, Dahl OE, Rosencher N, Kurth AA, Van Dijk CN, Frostick SP. Oral dabigatran etexilate vs subcutaneous enoxaparin for the prevention of venous thromboembolism after total knee replacement: the RE-MODEL randomized trial. J Thromb Haemost. 2007;5:2178–85.PubMedCrossRefGoogle Scholar
  50. 50.
    Ginsberg JS, Davidson BL, Comp PC, Francis CW, Friedman RJ, Huo MH, et al. Oral thrombin inhibitor dabigatran etexilate vs North American enoxaparin regimen for prevention of venous thromboembolism after knee arthroplasty surgery. J Arthroplasty. 2009;24:1–9.PubMedCrossRefGoogle Scholar
  51. 51.
    Lapidus LJ, Ponzer S, Pettersson H, de Bri E. Symptomatic venous thromboembolism and mortality in orthopaedic surgery—an observational study of 45,968 consecutive procedures. BMC Musculoskelet Disord. 2013;14:177.PubMedCentralPubMedCrossRefGoogle Scholar
  52. 52.
    Kakkos SK, Caprini JA, Geroulakos G, et al. Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism in high-risk patients. Cochrane Database Syst Rev. 2008;4, CD005258.PubMedGoogle Scholar
  53. 53.
    Roderick P, Ferris G, Wilson K, et al. Towards evidence based guidelines for the prevention of venous thromboembolism: systematic review of mechanical methods, oral anticoagulation, dextran and regional anaesthesia as thromboprophylaxis. Health Technol Assess. 2005;9:1–78.Google Scholar
  54. 54.
    Kakkos SK, Warwick D, Nicolaides AN, et al. Combined (mechanical and pharmacological) modalities for the prevention of venous thromboembolism in joint replacement surgery. J Bone Joint Surg (Br). 2012;94-B:729–34.CrossRefGoogle Scholar
  55. 55.•
    Lee YK, Chung CY, Koo KH, Lee KM, Ji HM, Park MS. Conflict of interest in the assessment of thromboprophylaxis after total joint arthroplasty: a systematic review. J Bone Joint Surg Am. 2012;94-A(1):27–33. This review shows that in the controversy of selecting from available thromboprophylaxis, surgeons need to be critical in appraising research papers and should be aware of any potential industry-related financial conflict of interest.Google Scholar
  56. 56.
    Husted H, Otte KS, Kristensen BB, Rsnes T, Wong C, Kehlet H. Low risk of thrombo-embolic complications after fast-track hip and knee arthroplasty. Acta Orthop. 2010;81(5):599–605.PubMedCentralPubMedCrossRefGoogle Scholar
  57. 57.
    Clarke MT, Green JS, Harper WM, et al. Screening for deep-venous thrombosis after hip and knee replacement without prophylaxis. J Bone Joint Surg (Br). 1997;79:787.CrossRefGoogle Scholar
  58. 58.
    Kim YH. The incidence of deep vein thrombosis after cementless and cemented knee replacement. J Bone Joint Surg (Br). 1990;72:779.Google Scholar
  59. 59.
    Lotke PA, Steinberg ME, Ecker ML. Significance of deep venous thrombosis in the lower extremity after total joint arthroplasty. Clin Orthop Relat Res. 1994;299:25.PubMedGoogle Scholar
  60. 60.
    McKenna R, Bachmann F, Kaushal SP, et al. Thromboembolic disease in patients undergoing total knee replacement. J Bone Joint Surg Am. 1976;58:928.PubMedGoogle Scholar
  61. 61.
    Fujita S, Hirota S, Oda T, et al. Deep venous thrombosis after total hip or total knee arthroplasty in patients in Japan. Clin Orthop Relat Res. 2000;375:168.PubMedCrossRefGoogle Scholar
  62. 62.
    Ko PS, Chan WF, Siu TH, et al. Deep venous thrombosis after total hip or knee arthroplasty in a “low-risk” Chinese population. J Arthroplasty. 2003;18:174.PubMedCrossRefGoogle Scholar
  63. 63.
    Piovella F, Wang CJ, Lu H, et al. Deep-vein thrombosis rates after major orthopedic surgery in Asia. An epidemiological study based on postoperative screening with centrally adjudicated bilateral venography. J Thromb Haemost. 2005;3:2664.PubMedCrossRefGoogle Scholar
  64. 64.
    Leizorovicz A. Epidemiology of post-operative venous thromboembolism in Asian patients. Results of the SMART venography study. Haematologica. 2007;92:1194.PubMedCrossRefGoogle Scholar
  65. 65.
    Cohen AT, On behalf of the Asia-Pacific Thrombosis Advisory Board. Asia-Pacific Thrombosis Advisory Board consensus paper on prevention of venous thromboembolism after major orthopaedic surgery. Thromb Haemost. 2010;104:919–30.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Nicolaas C. Budhiparama
    • 1
  • Matthew P. Abdel
    • 2
  • Nadia N. Ifran
    • 1
  • Sébastien Parratte
    • 3
  1. 1.Nicolaas Institute of Constructive Orthopaedics Research and Education Foundation for Arthroplasty & Sports MedicineMedistra HospitalJakartaIndonesia
  2. 2.Department of Orthopedic SurgeryMayo ClinicRochesterUSA
  3. 3.Department of Orthopedics and TraumatologySt. Marguerite HospitalMarseilleFrance

Personalised recommendations