1. THROMBOPROPHYLAXIS IN
ARTHROPLASTY – MYTHS AND
FACTS
Dr. Sushil Paudel

2. DVT PREVALENCE
 General surgery 35%
 Gynecologic Surgey 16%
 Hip Surgery 50 – 60%
 Knee reconstruction 40 – 84%
 Multi – system/Major trauma 50%
 Myocardial infarction 24%
 Neurosurgery 22%
 Spinal Cord Injury 67 – 100%
 Stroke 55%

ACCP 2001

3. MYTH 1
 DVT is fatal and decrease in incidence of
DVT reduces the chances of PE. Thus,
DVT and PE are correlated.
 DVT is not fatal(majority of them are
asymptomatic). What matters is
FATAL PE which may kill the patient.
Paul A Lotke, CORR, 2006

4. ARE DVT AND PE
CORRELATED??

5.  Although prophylactic agents affect the
incidence of deep venous thrombosis
(DVT), the rate of fatal PE remains the
same
Sheth NP, Lieberman JR. DVT prohylaxis in Total
joint reconstruction.Orthop .Clin N Am 41 (2010)
273–280.

6. MYTH 2
 Incidence of fatal PE after arthroplasty
is more than 1%.
 Risk of fatal PE has been
consistently reported over the past
decade to be approximately 0.06%
to 0.6%.
J Bone Joint Surg Br. 2009 May;91(5):645-8Cusick LA, Beverland DE.
Ansari S, Warwick D, Ackroyd CE, Newman JH.J Arthroplasty. 1997 Sep;12(6):599-60
Coventry MB, Nolan DR, Beckenbaugh RD. J Bone Joint Surg [Am]
1973;55-A:1487-92.
Johnson R, Green JR, Charnley J. Clin Orthop 1977;127:123-32.

7.  Rate of fatal PE does not appear to
vary with different regimens such as
low molecular weight heparins
(LMWHs), antithrombins, Coumadin, a
nd aspirin or with compressive
stockings
Sheth NP, Lieberman JR. DVT prohylaxis
in Total joint reconstruction.Orthop .Clin N
Am 41 (2010) 273–280.

8. MYTH 3
 Pharmacological prophylaxis routinely
recommended in THA/ TKA.
( ACCP, 2008)
 No consensus exists regarding the
optimal prophylaxis regimen
against thromboembolic disease in
orthopaedic patients
( AAOS, 2011)

9. THE GAP IN PROTECTION
50% of thrombi
formation begins
intraoperatively
The “Gap” in protection is when the
patient is at risk for DVT, but the
administration of pharmacological
prophylaxis cannot begin.
1. O’Meara and Kaufman. Prophylaxis for Venous Thromboembolism in Total Hip Arthroplasty: A Review. Orthopaedics. 1990 13(2):173-178

10.  Due to concerns for the development
of epidural hematoma, increased drain
in TKR & THR patients,
LMWH(pharmacological prophylaxis)is
generally administered 12-24hrs post-
op.
 Since the period of highest risk for
DVT is the first 24 hr period, this
modality is not protecting the
patients during the highest period
of risk.

12. ONSET OF ACTION
 Not only is LMWH many times not
administered until 12 – 24 hrs post –
op, it does not become fully effective
for upto 3-5 hrs.
LMWH 3 – 5 hrs
Warfarin 72 – 96 hrs
Mechanical Immediate

13. LMWH – HARMFUL OR
BENEFECIAL
 Conflicting reports
 Pro heparin reports have focused
only on presence or absence of
DVT not on final outcome
 Number of reports against LMWH
use are gradually ON RISE with
growing experience

14. There were more soft-tissue side effects in the patients who received
enoxaparin than in those who used the foot pump: there was more bruising
of the thigh and oozing of the wound (p < 0.001 for each), postoperative
drainage (578 compared with 492 milliliters; p = 0.014), and swelling of the
thigh (twenty compared with ten millimeters; p = 0.03). They concluded that
the foot pump is a suitable alternative to low-molecular-weight heparin
forprophylaxis against thromboembolism after total hip replacement and that
it produces fewer soft-tissue side effects.

17. COMPLICATIONS OF
PHARMACOLOGICAL
PROPHYLAXIS
Systemic
Local
According to Salvati (JBJS Am, 2000): Risk of life
threatening complications in Joint replacement are same
WITH or WITHOUT the use of LMWH

18. SYSTEMIC
COMPLICATIONS
 Bleeding
 Heparin induced thrombocytopenia
 CVA – Hemorrh. & Thromb.
 MI
 Renal & Hepatic infarction & bleeding
 Subcutaneous necrosis
 Epidural hematoma, Poor post-op analgesia!

19. LOCAL COMPLICATIONS
 Infection – 6 to 10 folds
 ↑ Discharge – resulting in increased
wound drain
 Wound hematoma
 ↑ Local pain
 ↑ swelling
 Delayed healing
 Marginal necrosis
 Decreased ROM

20. Use of anticoagulants requires
balancing the risk of clots against
the risk of bleeding.
Multimodal approach – closest to an
ideal method of prophylaxis

21. ALTERNATIVES?
 Pneumatic leg compression devices
 Foot compression devices
 Anti-embolism stockings

22. DVT PROPHYLAXIS
GUIDELINES
GUIDELINES PREFERRED MECHANICAL
PROHYLAXIS
ONLY
International Consensus
Statement (ICS) - 2006
Mechanical Yes
National Institute for
Health and Clinical
Excellence(NICE) - 2007
Mechanical Yes
American college of
Chest Physicians(ACCP)
- 2008
Anticoagulants No

23. Eighth ACCP-TJA
 All primary THA and TKA patients are
considered ‘‘high risk’’ regardless of patient
age, activity level, and comorbidities.
 LMWH*, warfarin (INR 2-3)*, fondaparinux*
 Up to 35 days for THA, hip fx
 The ACCP recommends against LDUH,
aspirin, dextran, TEDs, or venous foot pumps
as only means of prophylaxis
*ACCP grade 1A.
Geerts et al. Chest. 2008;133;381-453.

24. Orthopaedic surgeons response to 8th
ACCP Guidelines

25. AAOS Guidelines
American Academy of Orthopaedic Surgeons
Clinical Guideline on Prevention of
Symptomatic Pulmonary Embolism in
Patients Undergoing Total Hip or Knee
Arthroplasty
 Strictly for PE
 Do not address DVT
The AAOS guidelines have rejected the use of venographically
detected asymptomatic DVT as a valid outcome when assessing the
efficacy of thromboprophylaxis in clinical studies, and instead
consider fatal PE as only clinically relevant outcome

26.  RECOMMENDATIONS
No routine post-op duplex USG (strong)
Discontinue anti-platelet drugs before
surgery (Moderate)
Use of neuraxial anaesthesia (moderate)
Previous history of VTE should receive
both pharmacologic and mechanical
prophylaxis.(consensus)
Assessment of known bleeding disorders
like hemophilia, liver disease
(Consensus)

27. Known bleeding disorder or liver disease
should receive mechanical prophylaxis only.
(consensus)
Early mobilization post surgery(consensus)
Unable to recommend for or against IVC
filters(inconclusive)
No routine assessment of risk factors other
than previous history (inconclusive)
Use of pharmacologic and/or mechanical
compressive devices for prevention of
VTE(moderate) but unable to recommend
for or against any prophylaxis
(Inconclusive)

28. CURRENT PRACTICE
• Better pain management allowing
early mobilization
• Less traumatic surgery
• Regional aesthesia
• Mechanical prophylaxis like foot/
calf pump, stockings in all
patients.
• Pharmacological prophylaxis in
selected patients.

29. TAKE HOME MESSAGE
 DVT and PE are not related
 PE is fatal not DVT
 Optimal prophylaxis for DVT/PE is still a
mystery
 LMWH should be used in highly selected
cases(history of VTE).
 Mechanical methods provides immediate
prophylaxis at the time of highest
risk(within 24 hrs of surgery) without any
significant complications.

30. THANK YOU