Skip to main content
SpringerLink
Log in

Is routine chemoprophylaxis necessary for prevention of venous thromboembolism following knee arthroplasty in a low incidence population?

  • Knee Arthroplasty
  • Published:
Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript

Abstract

Background

Standard thromboprophylaxis guidelines have not been applied universally in regions with low incidence of deep-vein thrombosis (DVT) considering risks of chemoprophylaxis and low incidence itself. We evaluated the prevalence of DVT, efficacy and safety of chemoprophylaxis, and necessity of pharmacological prevention in a low DVT incidence population.

Methods

One hundred and forty-eight patients undergoing unilateral total knee arthroplasty (TKA) were prospectively randomized to receive either a placebo or 2.5 mg of fondaparinux once daily for 5 days. Doppler ultrasonography was performed preoperatively and 7 days after surgery. The primary efficacy outcome was prevalence of DVT up to day 7. Secondary efficacy outcome was prevalence of symptomatic venous thromboembolism (VTE) up to day 90. Primary and secondary safety outcomes were incidence of major and minor bleeding, respectively.

Results

The prevalence of total DVT was 25.7 % in placebo group and 6.8 % in fondaparinux group (p = 0.002) and the prevalence of proximal DVT was lower in both groups with no statistical difference. There was no symptomatic VTE in either group up to day 90. Although no major bleeding was developed, fondaparinux group had a significant increase of minor bleeding events (p < 0.001).

Conclusions

There remains low incidence of VTE following TKA in East Asians even without chemoprophylaxis. Although short-term fondaparinux protocol could reduce the incidence of overall DVT, its routine use seems debatable due to extremely rare proximal DVT and symptomatic PE and drug-related bleeding complication. However, modified and selective use of chemoprophylaxis would be considerable in high risk patients.

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

Fig. 1

Similar content being viewed by others

References

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

    Article  PubMed  CAS  Google Scholar 

  2. Kanchanabat B, Stapanavatr W, Meknavin S, Soorapanth C, Sumanasrethakul C, Kanchanasuttirak P (2011) Systematic review and meta-analysis on the rate of postoperative venous thromboembolism in orthopaedic surgery in Asian patients without thromboprophylaxis. Br J Surg 98:1356–1364

    Article  PubMed  CAS  Google Scholar 

  3. Kim KI, Cho KY, Jin W, Khurana SS, Bae DK (2011) Recent Korean perspective of deep vein thrombosis after total knee arthroplasty. J Arthroplast 26:1112–1116

    Article  Google Scholar 

  4. Kim YH, Kim JS (2002) Incidence and natural history of deep-vein thrombosis after total knee arthroplasty. A prospective, randomised study. J Bone Joint Surg Br 84:566–570

    Article  PubMed  Google Scholar 

  5. Watanabe H, Sekiya H, Kariya Y, Hoshino Y, Sugimoto H, Hayasaka S (2011) The incidence of venous thromboembolism before and after total knee arthroplasty using 16-row multidetector computed tomography. J Arthroplast 26:1488–1493

    Article  Google Scholar 

  6. Chin PL, Amin MS, Yang KY, Yeo SJ, Lo NN (2009) Thromboembolic prophylaxis for total knee arthroplasty in Asian patients: a randomised controlled trial. J Orthop Surg (Hong Kong) 17:1–5

    CAS  Google Scholar 

  7. Fuji T, Ochi T, Niwa S, Fujita S (2008) Prevention of postoperative venous thromboembolism in Japanese patients undergoing total hip or knee arthroplasty: two randomized, double-blind, placebo-controlled studies with three dosage regimens of enoxaparin. J Orthop Sci 13:442–451

    Article  PubMed  CAS  Google Scholar 

  8. Wang CJ, Wang JW, Weng LH, Hsu CC, Huang CC, Yu PC (2004) Prevention of deep-vein thrombosis after total knee arthroplasty in Asian patients. Comparison of low-molecular-weight heparin and indomethacin. J Bone Joint Surg Am 86:136–140

    PubMed  Google Scholar 

  9. Fong YK, Ruban P, Yeo SJ, Lee BP, Lo NN, Seow KH, Ng SC (2000) Use of low molecular weight heparin for prevention of deep vein thrombosis in total knee arthroplasty—a study of its efficacy in an Asian population. Ann Acad Med Singap 29:439–441

    PubMed  CAS  Google Scholar 

  10. American Academy of Orthopedic Surgeons (US). American Academy of Orthopedic Surgeons Clinical Guideline on Prevention of Symptomatic Pulmonary Embolism in Patients Undergoing Total Hip or Knee Arthroplasty [Internet]. 2007. p 63. http://www.aaos.org/Research/guidelines/PE_guideline.pdf

  11. National Institute for Health and Clinical Excellence. NICE Clinical guideline 46. Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery [Internet]. London, 2007. p. 163. http://www.nice.org.uk/Guidance/CG46/Guidance/pdf/English

  12. Lieberman JR (2011) The new AAOS clinical practice guidelines on venous thromboembolic prophylaxis: how to adapt them to your practice. J Am Acad Orthop Surg 19:717–721

    PubMed  Google Scholar 

  13. Mont MA, Jacobs JJ, Boggio LN, Bozic KJ, Della Valle CJ, Goodman SB, Lewis CG, Yates AJ Jr, Watters WC 3rd, Turkelson CM, Wies JL, Donnelly P, Patel N, Sluka P (2011) Preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Am Acad Orthop Surg 19:768–776

    PubMed  Google Scholar 

  14. Yokote R, Matsubara M, Hirasawa N, Hagio S, Ishii K, Takata C (2011) Is routine chemical thromboprophylaxis after total hip replacement really necessary in a Japanese population? J Bone Joint Surg Br 93:251–256

    Article  PubMed  CAS  Google Scholar 

  15. Burnett RS, Clohisy JC, Wright RW, McDonald DJ, Shively RA, Givens SA, Barrack RL (2007) Failure of the American College of Chest Physicians-1A protocol for lovenox in clinical outcomes for thromboembolic prophylaxis. J Arthroplast 22:317–324

    Article  Google Scholar 

  16. James PT (2004) Obesity: the worldwide epidemic. Clin Dermatol 22:276–280

    Article  PubMed  Google Scholar 

  17. Bauer KA, Eriksson BI, Lassen MR, Turpie AG (2001) Fondaparinux compared with enoxaparin for the prevention of venous thromboembolism after elective major knee surgery. N Engl J Med 345:1305–1310

    Article  PubMed  CAS  Google Scholar 

  18. Toftdahl K, Nikolajsen L, Haraldsted V, Madsen F, Tonnesen EK, Soballe K (2007) Comparison of peri- and intraarticular analgesia with femoral nerve block after total knee arthroplasty: a randomized clinical trial. Acta Orthopaedica 78:172–179

    Article  PubMed  Google Scholar 

  19. Blevins FT, Shaw B, Valeri CR, Kasser J, Hall J (1993) Reinfusion of shed blood after orthopaedic procedures in children and adolescents. J Bone Joint Surg Am 75:363–371

    PubMed  CAS  Google Scholar 

  20. Faris PM, Ritter MA, Keating EM, Valeri CR (1991) Unwashed filtered shed blood collected after knee and hip arthroplasties. A source of autologous red blood cells. J Bone Joint Surg Am 73:1169–1178

    PubMed  CAS  Google Scholar 

  21. Colwell CW Jr, Kwong LM, Turpie AG, Davidson BL (2006) Flexibility in administration of fondaparinux for prevention of symptomatic venous thromboembolism in orthopaedic surgery. J Arthroplast 21:36–45

    Article  Google Scholar 

  22. Comp PC, Spiro TE, Friedman RJ, Whitsett TL, Johnson GJ, Gardiner GA Jr, Landon GC, Jove M (2001) Prolonged enoxaparin therapy to prevent venous thromboembolism after primary hip or knee replacement. Enoxaparin clinical trial group. J Bone Joint Surg Am 83:336–345

    PubMed  Google Scholar 

  23. White RH, Henderson MC (2002) Risk factors for venous thromboembolism after total hip and knee replacement surgery. Curr Opin Pulm Med 8:365–371

    Article  PubMed  Google Scholar 

  24. Fuji T, Fujita S, Ochi T (2008) Fondaparinux prevents venous thromboembolism after joint replacement surgery in Japanese patients. Int Orthop 32:443–451

    Article  PubMed  Google Scholar 

  25. Turpie AG, Bauer KA, Eriksson BI, Lassen MR (2002) Fondaparinux vs enoxaparin for the prevention of venous thromboembolism in major orthopedic surgery: a meta-analysis of 4 randomized double-blind studies. Arch Intern Med 162:1833–1840

    Article  PubMed  CAS  Google Scholar 

  26. Lotke PA, Lonner JH (2006) The benefit of aspirin chemoprophylaxis for thromboembolism after total knee arthroplasty. Clin Orthop Relat Res 452:175–180

    Article  PubMed  Google Scholar 

  27. Parvizi J, Azzam K, Rothman RH (2008) Deep venous thrombosis prophylaxis for total joint arthroplasty: American academy of orthopaedic surgeons guidelines. J Arthroplasty 23(2–5):e1

    Google Scholar 

  28. Dorr LD, Gendelman V, Maheshwari AV, Boutary M, Wan Z, Long WT (2007) Multimodal thromboprophylaxis for total hip and knee arthroplasty based on risk assessment. J Bone Joint Surg Am 89:2648–2657

    Article  PubMed  Google Scholar 

  29. Pour AE, Keshavarzi NR, Purtill JJ, Sharkey PF, Parvizi J (2012) Is Venous foot pump effective in prevention of thromboembolic disease after joint arthroplasty: a meta-analysis. J Arthroplasty. 2012 Oct 24. pii: S0883–5403(12)00571-2. doi: 10.1016/j.arth.2012.08.003. [Epub ahead of print]

  30. Falck-Ytter Y, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S, Ortel TL, Pauker SG, Colwell CW Jr (2012) 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 141:e278S–e325S

    Article  PubMed  CAS  Google Scholar 

  31. Yamaguchi T, Hasegawa M, Niimi R, Sudo A (2010) Incidence and time course of asymptomatic deep vein thrombosis with fondaparinux in patients undergoing total joint arthroplasty. Thromb Res 126:e323–e326

    Article  PubMed  CAS  Google Scholar 

  32. Maynard MJ, Sculco TP, Ghelman B (1991) Progression and regression of deep vein thrombosis after total knee arthroplasty. Clin Orthop Relat Res 273:125–130

    PubMed  Google Scholar 

  33. White RH, Romano PS, Zhou H, Rodrigo J, Bargar W (1998) Incidence and time course of thromboembolic outcomes following total hip or knee arthroplasty. Arch Intern Med 158:1525–1531

    Article  PubMed  CAS  Google Scholar 

  34. Eikelboom JW, Quinlan DJ, Douketis JD (2001) Extended-duration prophylaxis against venous thromboembolism after total hip or knee replacement: a meta-analysis of the randomised trials. Lancet 358:9–15

    Article  PubMed  CAS  Google Scholar 

  35. Robinson KS, Anderson DR, Gross M, Petrie D, Leighton R, Stanish W, Alexander D, Mitchell M, Flemming B, Gent M (1997) Ultrasonographic screening before hospital discharge for deep venous thrombosis after arthroplasty: the post-arthroplasty screening study. A randomized, controlled trial. Ann Intern Med 127:439–445

    PubMed  CAS  Google Scholar 

  36. Schmidt B, Michler R, Klein M, Faulmann G, Weber C, Schellong S (2003) Ultrasound screening for distal vein thrombosis is not beneficial after major orthopedic surgery. A randomized controlled trial. Thromb Haemost 90:949–954

    PubMed  CAS  Google Scholar 

  37. Verlato F, Bruchi O, Prandoni P, Camporese G, Maso G, Busonera F, Girolami A, Andreozzi GM (2001) The value of ultrasound screening for proximal vein thrombosis after total hip arthroplasty—a prospective cohort study. Thromb Haemost 86:534–537

    PubMed  CAS  Google Scholar 

  38. Lieberman JR (2012) American College of Chest Physicians evidence-based guidelines for venous thromboembolic prophylaxis: the guideline wars are over. J Am Acad Orthop Surg 20:333–335

    Article  PubMed  Google Scholar 

  39. Bressollette L, Nonent M, Oger E, Garcia JF, Larroche P, Guias B, Scarabin PY, Mottier D (2001) Diagnostic accuracy of compression ultrasonography for the detection of asymptomatic deep venous thrombosis in medical patients—the TADEUS project. Thromb Haemost 86:529–533

    PubMed  CAS  Google Scholar 

  40. National Guideline C ACR Appropriateness Criteria® suspected lower extremity deep vein thrombosis. Agency for Healthcare Research and Quality (AHRQ). http://www.guideline.gov

  41. Righini M (2007) Is it worth diagnosing and treating distal deep vein thrombosis? No. J Thromb Haemost 5:55–59

    Article  PubMed  Google Scholar 

  42. Masuda EM, Kessler DM, Kistner RL, Eklof B, Sato DT (1998) The natural history of calf vein thrombosis: lysis of thrombi and development of reflux. J Vasc Surg 28:67–73 (discussion 73–64)

    Article  PubMed  CAS  Google Scholar 

  43. Piovella F, Wang CJ, Lu H, Lee K, Lee LH, Lee WC, Turpie AG, Gallus AS, Planes A, Passera R, Rouillon A (2005) 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 3:2664–2670

    Article  PubMed  CAS  Google Scholar 

  44. Song EK, Seon JK, P SJ, Cho SB, Choi MS et al (2008) Diagnosis of the deep vein thrombosis with multidetector-row computed tomographic venography after total knee arthroplasty. J Korean Orthop Assoc 43:294–300

    Article  Google Scholar 

  45. Kim YH, Yoo JH, Kim JS (2007) Factors leading to decreased rates of deep vein thrombosis and pulmonary embolism after total knee arthroplasty. J Arthroplasty 22:974–980

    Article  PubMed  Google Scholar 

  46. Miyagi J, Funabashi N, Suzuki M, Asano M, Kuriyama T, Komuro I, Moriya H (2007) Predictive indicators of deep venous thrombosis and pulmonary arterial thromboembolism in 54 subjects after total knee arthroplasty using multislice computed tomography in logistic regression models. Int J Cardiol 119:90–94

    Article  PubMed  Google Scholar 

  47. Chen CJ, Wang CJ, Huang CC (2008) The value of D-dimer in the detection of early deep-vein thrombosis after total knee arthroplasty in Asian patients: a cohort study. Thromb J 6:5

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

The authors would like to express our appreciation to Hye-Jin Seo, RN for the great assistance about this study.

Conflict of interest

The authors declare that they have no conflict of interest.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Center for Joint Diseases and Rheumatism, Kyung Hee University Hospital at Gangdong, 892 Dongnam-ro, Gangdong-gu, Seoul, 134-727, Korea

    Kye-Youl Cho, Kang-Il Kim & Sumit Khurana

  2. Department of Orthopaedic Surgery, Kyung Hee University Hospital, Seoul, Korea

    Dae-Kyung Bae

  3. Department of Radiology, Kyung Hee University Hospital at Gangdong, Seoul, Korea

    Wook Jin

Authors
  1. Kye-Youl Cho
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Kang-Il Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Sumit Khurana
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Dae-Kyung Bae
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Wook Jin
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Kang-Il Kim.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Cho, KY., Kim, KI., Khurana, S. et al. Is routine chemoprophylaxis necessary for prevention of venous thromboembolism following knee arthroplasty in a low incidence population?. Arch Orthop Trauma Surg 133, 551–559 (2013). https://doi.org/10.1007/s00402-013-1691-z

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00402-013-1691-z

Keywords

Search

Navigation