Synopsis

  • July 1st, 2015

A Brief Review of Current State of DVT Prophylaxis following Lower Limb Arthroplasty

Hip fracture surgery and lower extremity arthroplasty are associated with increased risk of both venous deep venous thrombosis (DVT) and bleeding. Currently there is no consensus on what is the best prophylactic practice; a protocol that can effectively prevent DVTs while not exposing patients to higher risks of bleeding.

Drescher et al. in a systematic review in 2014 showed that the overall rates of DVT were not different between the aspirin and the other anticoagulants’ group. Subgrouped by the type of surgery, there was a trend favoring anticoagulation following hip fracture repair but not knee or hip arthroplasty. The risk of bleeding was lower with aspirin than anticoagulants following hip fracture repair, with a nonsignificant trend favoring aspirin after arthroplasty. Rates of pulmonary embolism were too low to provide reliable estimates. They concluded that compared with anticoagulation, aspirin may be associated with higher risks of DVT following hip fracture, although bleeding rates were substantially lower. Aspirin was similarly effective after lower extremity arthroplasty and was associated with lower risks of bleeding.

Yoe Zou et al. in a prospective study compared the efficacy and safety of aspirin, rivaroxaban and low-molecular-weight heparin for post total knee arthroplasty DVT. Their results showed that Rivaroxaban has a positive anticoagulation effect but leads to increased both postoperative blood loss and wound complications, while, no significant difference in post-TKA DVT prophylaxis was found between aspirin and LMWH.

In another study published in 2014 in BJJ, the authors found that the use of Dabigatran led to a significant increase in postoperative wound drainage (20% with Dabigatran, 5% with multimodal regimen), which resulted in increase duration of hospital stay. On the other hand, the rate of thromboembolism in patients receiving Dabigatran was higher than those receiving multimodal thromboprophylaxis regimen.

In a study published in 2014, Colwell et al. showed that major bleeding in total hip arthroplasty was less using the mobile compression device than using LMWH. Use of a mobile compression device with or without aspirin for patients undergoing TJA provided a non-inferior risk for developing VTE compared with current pharmacological protocols.

Nam et al. in 2015 demonstrated that in appropriately selected patients, mobile compression devices with aspirin showed promise in VTE prevention following simultaneous bilateral TKA.

Parvizi et al. showed that in patients undergoing THA/TKA without prior VTE, aspirin is a more cost-effective prophylactic agent than warfarin. However, warfarin might be a better prophylaxis in TKA in patients with high probability of VTE and very low probability of bleeding.

In a recent publication in Journal of Surgery, 2015, the authors showed that staged prophylaxis using LMWH followed by aspirin is a safe and effective thromboprophylactic regime that is associated with a very low rate of fatal PE and all-cause mortality.

In June 2015, Parvizi et al. stated that in patients undergoing lower limb arthroplasty, aspirin was an independent predictor of decreased cost of index hospitalization and total episodes of care charges, achieved largely through a shorter length of hospitalization.

With a brief look at the 2014 and 2015 literature, part of which is provided here, it is obvious that the use of aspirin has been highlighted as an acceptable chemoprophylactic agent for patients undergoing lower limb TJA. Warfarin and low-molecular-weight heparins remain widely used, but maintaining therapeutic levels of warfarin remains a challenge and LMWH has not shown itself to be superior to any of the other chemoprophylactic agents. The newer oral anticoagulants such as factor Xa inhibitors and direct thrombin inhibitors, may have superior efficacy, but their safety profile must be studied further. Additionally, the use of mechanical prophylaxis continues to rise in popularity because of their ability to minimize bleeding complications.