Skip to main content

Advertisement

Log in

Aspirin: An Alternative for Pulmonary Embolism Prophylaxis After Arthroplasty?

  • Symposium: 2013 Hip Society Proceedings
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

The most effective agent for prophylaxis against venous thromboembolic disease after total joint arthroplasty (TJA) remains unknown. The paucity of literature comparing different methods of pulmonary embolism (PE) prophylaxis and fear of litigation make it difficult for surgeons to abandon the use of aggressive chemical prophylaxis.

Questions/purposes

We compared the (1) overall frequency of symptomatic PE, (2) risk of symptomatic PE after propensity matching that adjusted for potentially confounding variables, and (3) other complications and length of stay before and after propensity matching in patients undergoing TJA at our institution who received either aspirin or warfarin prophylaxis.

Methods

A total of 28,923 patients underwent TJA between January 2000 and June 2012 at our institution, had either aspirin (325 mg twice daily; 2800 patients) or warfarin prophylaxis (26,123 patients), and were registered in our institutional electronic database. The incidence of symptomatic PE, symptomatic deep vein thrombosis (DVT), hematoma formation, infection, wound complications, and mortality up to 90 days postoperatively was collected from the database. We performed multivariate analysis and 3:1 and 5:1 propensity score matching for comorbid and demographic variables.

Results

The overall symptomatic PE rate was lower (p < 0.001) in patients receiving aspirin (0.14%) than in the patients receiving warfarin (1.07%). This difference did not change after matching. The aspirin group also had significantly fewer symptomatic DVTs and wound-related problems and shorter hospital stays, which did not change after matching.

Conclusions

After publication of the American Academy of Orthopaedic Surgeons’ guidelines, some surgeons have utilized aspirin as thromboprophylaxis after TJA. Based on our findings from a large institutional database, aspirin offers suitable prophylaxis against symptomatic PE in selected patients.

Level of Evidence

Level III, therapeutic study. See Instructions 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

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

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. Anon. Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial. Lancet. 2000;355:1295–1302.

  2. Berend KR, Lombardi AV Jr. Multimodal venous thromboembolic disease prevention for patients undergoing primary or revision total joint arthroplasty: the role of aspirin. Am J Orthop. 2006;35:24–29.

    PubMed  Google Scholar 

  3. Bjørnarå BT, Gudmundsen TE, Dahl OE. Frequency and timing of clinical venous thromboembolism after major joint surgery. J Bone Joint Surg Br. 2006;88:386–391.

    Article  PubMed  Google Scholar 

  4. Boyd HS. VTE prevention in major orthopedic surgery. Cleve Clin J Med. 2008;75:471–472; author reply 472–473.

    Google Scholar 

  5. Bozic KJ, Vail TP, Pekow PS, Maselli JH, Lindenauer PK, Auerbach AD. Does aspirin have a role in venous thromboembolism prophylaxis in total knee arthroplasty patients? J Arthroplasty. 2010;25:1053–1060.

    Article  PubMed  Google Scholar 

  6. Brookenthal KR, Freedman KB, Lotke PA, Fitzgerald RH, Lonner JH. A meta-analysis of thromboembolic prophylaxis in total knee arthroplasty. J Arthroplasty. 2001;16:293–300.

    Article  CAS  PubMed  Google Scholar 

  7. 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(6 suppl 1):20–24.

    Article  PubMed  Google Scholar 

  8. Catella-Lawson F, Reilly MP, Kapoor SC, Cucchiara AJ, DeMarco S, Tournier B, Vyas SN, Fitzgerald GA. Cyclooxygenase inhibitors and the antiplatelet effects of aspirin. N Engl J Med. 2001;345:1809–1817.

    Article  CAS  PubMed  Google Scholar 

  9. Charlson M, Szatrowski TP, Peterson J, Gold J. Validation of a combined comorbidity index. J Clin Epidemiol. 1994;47:1245–1251.

    Article  CAS  PubMed  Google Scholar 

  10. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–383.

    Article  CAS  PubMed  Google Scholar 

  11. Cusick LA, Beverland DE. The incidence of fatal pulmonary embolism after primary hip and knee replacement in a consecutive series of 4253 patients. J Bone Joint Surg Br. 2009;91:645–648.

    Article  CAS  PubMed  Google Scholar 

  12. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45:613–619.

    Article  CAS  PubMed  Google Scholar 

  13. Falck-Ytter Y, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S, Ortel TL, Pauker SG, Colwell CW Jr; 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–e325S.

  14. Fender D, Harper WM, Thompson JR, Gregg PJ. Mortality and fatal pulmonary embolism after primary total hip replacement: results from a regional hip register. J Bone Joint Surg Br. 1997;79:896–899.

    Article  CAS  PubMed  Google Scholar 

  15. Fitzgerald RH Jr, Spiro TE, Trowbridge AA, Gardiner GA Jr, Whitsett TL, O’Connell MB, Ohar JA, Young TR; Enoxaparin Clinical Trial Group. Prevention of venous thromboembolic disease during primary total knee arthroplasty. J Bone Joint Surg Am. 2001;83:900–906.

    Google Scholar 

  16. Francis CW, Davidson BL, Berkowitz SD, Lotke PA, Ginsberg JS, Lieberman JR, Webster AK, Whittle JP, Peters GR, Colwell CW Jr. Ximelagatran versus warfarin for the prevention of thromboembolism after total knee arthroplasty: a randomized double blind trial. Ann Intern Med. 2002;137:648–655.

    Article  CAS  PubMed  Google Scholar 

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

    CAS  PubMed  Google Scholar 

  18. 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 Edition). Chest. 2008;133(6 suppl):381S–453S.

    Google Scholar 

  19. Hamilton SC, Whang WW, Anderson BJ, Bradbury TL, Erens GA, Roberson JR. Inpatient enoxaparin and outpatient aspirin chemoprophylaxis regimen after primary hip and knee arthroplasty: a preliminary study. J Arthroplasty. 2012;27:1594–1598.

    Article  PubMed  Google Scholar 

  20. Heit JA, Berkowitz SD, Bona R, Cabanas V, Corson JD, Elliott CG, Lyons R. Efficacy and safety of low molecular weight heparin (ardeparin sodium) compared to warfarin for the prevention of venous thromboembolism after total knee replacement surgery: a double-blind, dose-ranging study. Ardeparin Arthroplasty Study Group. Thromb Haemost. 1997;77:32–38.

    CAS  PubMed  Google Scholar 

  21. Hirsh J. Oral anticoagulant drugs. N Engl J Med. 1991;324:1865–1875.

    Article  CAS  PubMed  Google Scholar 

  22. Hull RD, Raskob GE. Prophylaxis of venous thromboembolic disease following hip and knee surgery. J Bone Joint Surg Am. 1986;68:146–150.

    CAS  PubMed  Google Scholar 

  23. Johanson NA, Lachiewicz PF, Lieberman JR, Lotke PA, Parvizi J, Pellegrini V, Stringer TA, Tornetta P 3rd, Haralson RH 3rd, Watters WC 3rd. American Academy of Orthopaedic Surgeons clinical practice guideline on prevention of symptomatic pulmonary embolism in patients undergoing total hip or knee arthroplasty. J Bone Joint Surg Am. 2009;91:1756–1757.

    Article  PubMed  Google Scholar 

  24. Leclerc JR, Geerts WH, Desjardins L, Laflamme GH, L’Esperance B, Demers C, Kassis J, Cruickshank M, Whitman L, Delorme F. Prevention of venous thromboembolism after knee arthroplasty: a randomized, double blind trial, comparing enoxaparin with warfarin. Ann Intern Med. 1996;124:619–626.

    Article  CAS  PubMed  Google Scholar 

  25. Leclerc JR, Gent M, Hirsh J, Geerts WH, Ginsberg JS. The incidence of symptomatic venous thromboembolism after enoxaparin prophylaxis in lower extremity arthroplasty: a cohort study of 1,984 patients. Canadian Collaborative Group. Chest. 1998;114(2 suppl evidence):115S–118S.

    Google Scholar 

  26. Lieberman JR, Wollaeger J, Dorey F, Thomas BJ, Kilgus DJ, Grecula MJ, Finerman GA, Amstutz HC. The efficacy of prophylaxis with low-dose warfarin for prevention of pulmonary embolism following total hip arthroplasty. J Bone Joint Surg Am. 1997;79:319–325.

    CAS  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  28. Lotke PA, Palevsky H, Keenan AM, Meranze S, Steinberg ME, Ecker ML, Kelley MA. Aspirin and warfarin for thromboembolic disease after total joint arthroplasty. Clin Orthop Relat Res. 1996;324:251–258.

    Article  PubMed  Google Scholar 

  29. Paiement G, Wessinger SJ, Waltman AC, Harris WH. Low-dose warfarin versus external pneumatic compression for prophylaxis against venous thromboembolism following total hip replacement. J Arthroplasty. 1987;2:23–26.

    Article  CAS  PubMed  Google Scholar 

  30. Parvizi J, Ghanem E, Joshi A, Sharkey PF, Hozack WJ, Rothman RH. Does “excessive” anticoagulation predispose to periprosthetic infection? J Arthroplasty. 2007;22(6 suppl 2):24–28.

    Article  PubMed  Google Scholar 

  31. Parvizi J, Kahl LK, Dalsey C. Aggressive anticoagulation after TJA: an evaluation of the ACCP guidelines for thromboprophylaxis. J Long Term Eff Med Implants. 2007;17:359–365.

    Article  PubMed  Google Scholar 

  32. Patrono C, Coller B, FitzGerald GA, Hirsh J, Roth G. Platelet-active drugs: the relationships among dose, effectiveness, and side effects: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3 suppl):234S–264S.

    Article  CAS  PubMed  Google Scholar 

  33. Pellegrini VD Jr, Sharrock NE, Paiement GD, Morris R, Warwick DJ. Venous thromboembolic disease after total hip and knee arthroplasty: current perspectives in a regulated environment. Instr Course Lect. 2008;57:637–661.

    PubMed  Google Scholar 

  34. Poultsides LA, Gonzalez Della Valle A, Memtsoudis SG, Ma Y, Roberts T, Sharrock N, Salvati E. Meta-analysis of cause of death following total joint replacement using different thromboprophylaxis regimens. J Bone Joint Surg Br. 2012;94:113–121.

    Article  CAS  PubMed  Google Scholar 

  35. Pulido L, Parvizi J, Macgibeny M, Sharkey PF, Purtill JJ, Rothman RH, Hozack WJ. In hospital complications after total joint arthroplasty. J Arthroplasty. 2008;23(6 suppl 1):139–145.

    Article  PubMed  Google Scholar 

  36. Reitman RD, Emerson RH, Higgins LL, Tarbox TR. A multimodality regimen for deep venous thrombosis prophylaxis in total knee arthroplasty. J Arthroplasty. 2003;18:161–168.

    Article  PubMed  Google Scholar 

  37. Sachs RA, Smith JH, Kuney M, Paxton L. Does anticoagulation do more harm than good? A comparison of patients treated without prophylaxis and patients treated with low-dose warfarin after total knee arthroplasty. J Arthroplasty. 2003;18:389–395.

    Article  PubMed  Google Scholar 

  38. Sharrock NE, Gonzalez Della Valle A, Go G, Lyman S, Salvati EA. Potent anticoagulants are associated with a higher all-cause mortality rate after hip and knee arthroplasty. Clin Orthop Relat Res. 2008;466:714–721.

    Article  PubMed  Google Scholar 

  39. Vresilovic EJ, Hozack WJ, Booth RE Jr, Rothman RH. Comparative risk of early postoperative pulmonary embolism after cemented total knee versus total hip arthroplasty with low-dose warfarin prophylaxis. Am J Knee Surg. 1996;9:2–6.

    CAS  PubMed  Google Scholar 

  40. Vulcano E, Gesell M, Esposito A, Ma Y, Memtsoudis SG, Gonzalez Della Valle A. Aspirin for elective hip and knee arthroplasty: a multimodal thromboprophylaxis protocol. Int Orthop. 2012;36:1995–2002.

    Article  PubMed Central  PubMed  Google Scholar 

  41. White RH, Meehan JP, Romano PS. Re: Does aspirin have a role in venous thromboembolism prophylaxis in total knee arthroplasty patients? J Arthroplasty. 2010;25:667; author reply 667–668.

  42. Winters BS, Solarz M, Jacovides CL, Purtill JJ, Rothman RH, Parvizi J. Overdiagnosis of pulmonary embolism: evaluation of a hypoxia algorithm designed to avoid this catastrophic problem. Clin Orthop Relat Res. 2012;470:497–502.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

The authors thank our statistician Mitchell G. Maltenfort PhD for his contribution in the statistical analyses conducted in this study. We also acknowledge the efforts of Camilo Restrepo MD in managing our database and assisting in the editing of this paper.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Javad Parvizi MD, FRCS.

Additional information

Each author certifies that he or she, or a member of his or her immediate family, has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the 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 or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

About this article

Cite this article

Raphael, I.J., Tischler, E.H., Huang, R. et al. Aspirin: An Alternative for Pulmonary Embolism Prophylaxis After Arthroplasty?. Clin Orthop Relat Res 472, 482–488 (2014). https://doi.org/10.1007/s11999-013-3135-z

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11999-013-3135-z

Keywords

Navigation