Drugs & Aging

, Volume 25, Issue 7, pp 551–558

Thromboprophylaxis in Elderly Patients Undergoing Major Orthopaedic Surgery

  • Clifford W. ColwellJr
  • Mary E. Hardwick
Therapy In Practice

Abstract

The overall aging of our population and the success of total joint arthroplasty has rapidly increased the number of these surgeries performed. With total joint arthroplasty of the lower extremity, the risk of development of venous thrombosis is significant. As people age, co-morbidities and the risk of thrombosis also increase. A range of prophylactic strategies that can dramatically reduce the prevalence of venous thromboembolism in the aging population are available. Thromboprophylaxis has been shown in many randomized trials to reduce the incidence of venous thromboembolism in patients undergoing total joint arthroplasty.

Use of any prophylaxis has to be examined in terms of risks and benefits to the patient. Generalized use of the guidelines published in Chest has substantially reduced the incidence of venous thromboembolism in the hospitalized elderly patient undergoing major orthopaedic surgery of the lower extremity. Adhering to published evidence-based guidelines can greatly decrease the number of thromboembolic events seen in elderly patients undergoing major orthopaedic surgery.

References

  1. 1.
    American Academy of Orthopaedic Surgeons. Patient demographics: information about orthopaedic patients and conditions [online]. Available from URL: http://www.aaos.org/Research/stats/patientstats.asp [Accessed 2007 Oct 10]
  2. 2.
    Canadian Joint Replacement Registry. 2006 CJRR report: total hip and total knee replacements in Canada. Ottawa (ON): Canadian Institute for Health Information, 2006Google Scholar
  3. 3.
    Keenan CR, White RH. Age as a risk factor for venous thromboembolism after major surgery. Curr Opin Pulm Med 2005; 11(5): 398–402PubMedCrossRefGoogle Scholar
  4. 4.
    Dahl OE, Aspelin T, Arnesen H, et al. Increased activation of coagulation and formation of late deep venous thrombosis following discontinuation of thromboprophylaxis after hip replacement surgery. Thromb Res 1995; 80(4): 299–306PubMedCrossRefGoogle Scholar
  5. 5.
    Dahl OE, Gudmundsen TE, Bjornara BT, et al. Risk of clinical pulmonary embolism after joint surgery in patients receiving low-molecular-weight heparin prophylaxis in hospital: a 10-year prospective register of 3,954 patients. Acta Orthop Scand 2003; 74(3): 299–304PubMedCrossRefGoogle Scholar
  6. 6.
    White RH, Romano PS, Zhou H, et al. Incidence and time course of thromboembolic outcomes following total hip or knee arthroplasty. Arch Intern Med 1998; 158(14): 1525–31PubMedCrossRefGoogle Scholar
  7. 7.
    Hull RD, Pineo GF, Stein PD, et al. Extended out-of-hospital low-molecular-weight heparin prophylaxis against deep venous thrombosis in patients after elective hip arthroplasty: a systematic review. Ann Intern Med 2001; 135(10): 858–69PubMedGoogle Scholar
  8. 8.
    Planes A, Vochelle N, Darmon JY, et al. Risk of deep-venous thrombosis after hospital discharge in patients having undergone total hip replacement: double-blind randomised comparison of enoxaparin versus placebo. Lancet 1996; 348(9022): 224–8PubMedCrossRefGoogle Scholar
  9. 9.
    Prandoni P, Bruchi O, Sabbion P, et al. Prolonged thromboprophylaxis with oral anticoagulants after total hip arthroplasty: a prospective controlled randomized study. Arch Intern Med 2002; 162(17): 1966–71PubMedCrossRefGoogle Scholar
  10. 10.
    White RH, Gettner S, Newman JM, et al. Predictors of rehospitalization for symptomatic venous thromboembolism after total hip arthroplasty. N Engl J Med 2000; 343(24): 1758–64PubMedCrossRefGoogle Scholar
  11. 11.
    Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126 (3 Suppl.): 338S–400SPubMedCrossRefGoogle Scholar
  12. 12.
    Geerts WH, Heit JA, Clagett GP, et al. Prevention of venous thromboembolism. Chest 2001; 119 (1 Suppl.): 132S–75SPubMedCrossRefGoogle Scholar
  13. 13.
    Lotke PA, Palevsky H, Keenan AM, et al. Aspirin and warfarin for thromboembolic disease after total joint arthroplasty. Clin Orthop Relat Res 1996; (324): 251–8Google Scholar
  14. 14.
    Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial. Lancet 2000; 355(9212): 1295–302Google Scholar
  15. 15.
    Collaborative overview of randomised trials of antiplatelet therapy: I. Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. Antiplatelet Trialists Collaboration. BMJ 1994; 308(6921): 81–106Google Scholar
  16. 16.
    Mari D, Mannucci PM, Coppola R, et al. Hypercoagulability in centenarians: the paradox of successful aging. Blood 1995; 85(11): 3144–9PubMedGoogle Scholar
  17. 17.
    Campbell NR, Hull RD, Brant R, et al. Aging and heparin-related bleeding. Arch Intern Med 1996; 156(8): 857–60PubMedCrossRefGoogle Scholar
  18. 18.
    Heit JA. Risk factors for venous thromboembolism. Clin Chest Med 2003; 24(1): 1–12PubMedCrossRefGoogle Scholar
  19. 19.
    Samama CM, Albaladejo P, Benhamou D, et al. Venous thromboembolism prevention in surgery and obstetrics: clinical practice guidelines. Eur J Anaesthesiol 2006; 23(2): 95–116PubMedCrossRefGoogle Scholar
  20. 20.
    Sellier E, Labarere J, Bosson JL, et al. Effectiveness of a guideline for venous thromboembolism prophylaxis in elderly post-acute care patients: a multicenter study with systematic ultrasonographic examination. Arch Intern Med 2006; 166(19): 2065–71PubMedCrossRefGoogle Scholar
  21. 21.
    Hirsh J, Raschke R. Heparin and low-molecular-weight heparin: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126 (3 Suppl.): 188S–203SPubMedCrossRefGoogle Scholar
  22. 22.
    Morris TA, Castrejon S, Devendra G, et al. No difference in risk for thrombocytopenia during treatment of pulmonary embolism and deep venous thrombosis with either low-molecular-weight heparin or unfractionated heparin: a meta-analysis. Chest 2007; 132(4): 1131–9PubMedCrossRefGoogle Scholar
  23. 23.
    Weitz JI. Low-molecular-weight heparins. N Engl J Med 1997; 337(10): 688–98PubMedCrossRefGoogle Scholar
  24. 24.
    Weitz JI, Hirsh J, Samama MM. New anticoagulant drugs: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126 (3 Suppl.): 265S–86SPubMedCrossRefGoogle Scholar
  25. 25.
    Lassen MR, Bauer KA, Eriksson BI, et al. Postoperative fondaparinux versus preoperative enoxaparin for prevention of venous thromboembolism in elective hip-replacement surgery: a randomised double-blind comparison. Lancet 2002; 359(9319): 1715–20PubMedCrossRefGoogle Scholar
  26. 26.
    Turpie AG, Bauer KA, Eriksson BI, et al. Postoperative fondaparinux versus postoperative enoxaparin for prevention of venous thromboembolism after elective hip-replacement surgery: a randomised double-blind trial. Lancet 2002; 359(9319): 1721–6PubMedCrossRefGoogle Scholar
  27. 27.
    Bauer KA, Eriksson BI, Lassen MR, et al. Fondaparinux compared with enoxaparin for the prevention of venous thromboembolism after elective major knee surgery. N Engl J Med 2001; 345(18): 1305–10PubMedCrossRefGoogle Scholar
  28. 28.
    Eriksson BI, Bauer KA, Lassen MR, et al. Fondaparinux compared with enoxaparin for the prevention of venous thromboembolism after hip-fracture surgery. N Engl J Med 2001; 345(18): 1298–304PubMedCrossRefGoogle Scholar
  29. 29.
    Eriksson BI, Lassen MR, Colwell Jr CW. Efficacy of fondaparinux for thromboprophylaxis in hip fracture patients. J Arthroplasty 2004; 19 (7 Suppl. 2): 78–81PubMedCrossRefGoogle Scholar
  30. 30.
    Kuo KH, Kovacs MJ. Fondaparinux: a potential new therapy for HIT. Hematology 2005; 10(4): 271–5PubMedCrossRefGoogle Scholar
  31. 31.
    Papadopoulos S, Flynn JD, Lewis DA. Fondaparinux as a treatment option for heparin-induced thrombocytopenia. Pharmacotherapy 2007; 27(6): 921–6PubMedCrossRefGoogle Scholar
  32. 32.
    Ansell J, Hirsh J, Poller L, et al. The pharmacology and management of the vitamin K antagonists: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126 (3 Suppl.): 204S–33SPubMedCrossRefGoogle Scholar
  33. 33.
    Fihn SD, Callahan CM, Martin DC, et al. The risk for and severity of bleeding complications in elderly patients treated with warfarin: the National Consortium of Anticoagulation Clinics. Ann Intern Med 1996; 124(11): 970–9PubMedGoogle Scholar
  34. 34.
    US FDA. FDA clears genetic lab test for warfarin sensitivity [press release]. 2007 Oct 23Google Scholar
  35. 35.
    Caldwell MD, Berg RL, Zhang KQ, et al. Evaluation of genetic factors for warfarin dose prediction. Clin Med Res 2007; 5(1): 8–16PubMedCrossRefGoogle Scholar
  36. 36.
    Patrono C, Coller B, FitzGerald GA, et al. 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–64SPubMedCrossRefGoogle Scholar
  37. 37.
    Gent M, Hirsh J, Ginsberg JS, et al. Low-molecular-weight heparinoid orgaran is more effective than aspirin in the prevention of venous thromboembolism after surgery for hip fracture. Circulation 1996; 93(1): 80–4PubMedCrossRefGoogle Scholar
  38. 38.
    Graor RA, Steward JH, Lotke PA, et al. RD Heparin (ardeparin sodium) vs aspirin to prevent deep venous thrombosis after hip or knee replacement surgery [abstract]. Chest 1992; 102 Suppl.: 118SGoogle Scholar
  39. 39.
    Lotke PA, Lonner JH. The benefit of aspirin chemoprophylaxis for thromboembolism after total knee arthroplasty. Clin Orthop Relat Res 2006; 452: 175–80PubMedCrossRefGoogle Scholar
  40. 40.
    Hull RD, Pineo GF, Francis C, et al. 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(14): 2199–207PubMedCrossRefGoogle Scholar
  41. 41.
    Hull RD, Pineo GF, Francis C, et al. Low-molecular-weight heparin prophylaxis using dalteparin extended out-of-hospital vs in-hospital warfarin/out-of-hospital placebo in hip arthroplasty patients: a double-blind, randomized comparison. North American Fragmin Trial Investigators. Arch Intern Med 2000; 160(14): 2208–15PubMedCrossRefGoogle Scholar
  42. 42.
    Rowlingson JC, Hanson PB. Neuraxial anesthesia and low-molecular-weight heparin prophylaxis in major orthopedic surgery in the wake of the latest American Society of Regional Anesthesia guidelines. Anesth Analg 2005; 100(5): 1482–8PubMedCrossRefGoogle Scholar
  43. 43.
    Horlocker TT, Wedel DJ, Benzon H, et al. Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med 2003; 28(3): 172–97PubMedGoogle Scholar
  44. 44.
    Eriksson BI, Lassen MR. Duration of prophylaxis against venous thromboembolism with fondaparinux after hip fracture surgery: a multicenter, randomized, placebo-controlled, double-blind study. Arch Intern Med 2003; 163(11): 1337–42PubMedCrossRefGoogle Scholar
  45. 45.
    Pass SE, Simpson RW. Discontinuation and reinstitution of medications during the perioperative period. Am J Health Syst Pharm 2004; 61(9): 899–912PubMedGoogle Scholar
  46. 46.
    White RH, McKittrick T, Hutchinson R, et al. Temporary discontinuation of warfarin therapy: changes in the international normalized ratio. Ann Intern Med 1995; 122(1): 40–2PubMedGoogle Scholar
  47. 47.
    Kovacs MJ, Kearon C, Rodger M, et al. Single-arm study of bridging therapy with low-molecular-weight heparin for patients at risk of arterial embolism who require temporary interruption of warfarin. Circulation 2004; 110(12): 1658–63PubMedCrossRefGoogle Scholar
  48. 48.
    Sridhar R, Grigg AP. The perioperative management of anticoagulation. Aust Prescr 2000; 23(1): 13–6Google Scholar
  49. 49.
    Jaffer AK, Brotman DJ, Chukwumerije N. When patients on warfarin need surgery. Cleve Clin J Med 2003; 70(11): 973–84PubMedCrossRefGoogle Scholar
  50. 50.
    Dunn AS, Spyropoulos AC, Turpie AG. Bridging therapy in patients on long-term oral anticoagulants who require surgery: the ProspectivePerioperative EnoxaparinCohort Trial (PROSPECT). J Thromb Haemost 2007; 5(11): 2211–8PubMedCrossRefGoogle Scholar
  51. 51.
    Ansell J, Hirsh J, Dalen J, et al. Managing oral anticoagulant therapy. Chest 2001; 119 (1 Suppl.): 22S–38SPubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2008

Authors and Affiliations

  • Clifford W. ColwellJr
    • 1
  • Mary E. Hardwick
    • 1
  1. 1.Shiley Center for Orthopaedic Research and Education at Scripps ClinicLa JollaUSA

Personalised recommendations