Multimodal Prophylaxis for THA with Mechanical Compression

Department of Orthopaedics, University of North Carolina, Chapel 3151 Bioinformatics Bldg, CB 7055, Chapel Hill, NC 27599-7055, USA.
Clinical Orthopaedics and Related Research (Impact Factor: 2.77). 01/2007; 453(453):225-30. DOI: 10.1097/01.blo.0000238861.84733.9d
Source: PubMed

ABSTRACT We used mechanical thromboembolism prophylaxis using intraoperative thigh-calf pneumatic compression and other measures in 1032 consecutive primary and revision total hip arthroplasties. No chemical prophylactic measures were used until after duplex ultrasonography was performed by experienced technologists before discharge. Asymptomatic proximal thrombi were treated with low molecular weight heparin and warfarin, whereas those patients with a negative scan or distal thrombi only were advised to take aspirin 325 mg twice a day for 6 weeks. Regional anesthesia was used in 95% of the arthroplasties. Using this protocol, the 30-day mortality was 0.3%. There was one autopsy-proven fatal pulmonary embolism (0.09%). One other patient died suddenly with cardiac arrest after abdominal pain and vomiting, but no autopsy was performed. Symptomatic pulmonary embolism occurred in seven patients (0.7%), four occurring early and three late. Only one of these seven patients had a positive duplex scan. Deep vein thrombosis occurred in 41 patients (3.9%) and 35 remained asymptomatic. We observed no association between type of surgery (primary or revision), age, gender or preoperative diagnosis and pulmonary embolism or deep vein thrombosis. The data confirm the efficacy of a multimodal protocol with thigh-calf mechanical prophylaxis for almost all patients undergoing primary or revision total hip arthroplasty.

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    • "Others have supported this belief. Thus, some propose differentiated DVT prophylaxis by identifying low- and high-risk patients after THA and TKA, balancing the need for prophylaxis against the risk of bleeding (Lachiewicz and Soileau 2006, 2007, Dorr et al. 2007). Such regimens have led to incidences of 0.25% for (non-fatal) PE after THA and TKA (Dorr et al. 2007), and 0.35% for PE after TKA and 0.7% after THA (Lachiewicz and Soileau 2006 and 2007). "
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    ABSTRACT: Pharmacological prophylaxis can reduce the risk of deep venous thrombosis (DVT), pulmonary embolism (PE), and death, and it is recommended 10–35 days after total hip arthroplasty (THA) and at least 10 days after total knee arthroplasty (TKA). However, early mobilization might also reduce the risk of DVT and thereby the need for prolonged prophylaxis, but this has not been considered in the previous literature. Here we report our results with short-duration pharmacological prophylaxis combined with early mobilization and reduced hospitalization. 1,977 consecutive, unselected patients were operated with primary THA, TKA, or bilateral simultaneous TKA (BSTKA) in a well-described standardized fast-track set-up from 2004–2008. Patients received DVT prophylaxis with low-molecular-weight heparin starting 6–8 h after surgery until discharge. All re-admissions and deaths within 30 and 90 days were analyzed using the national health register, concentrating especially on clinical DVT (confirmed by ultrasound and elevated D-dimer), PE, or sudden death. Numbers were correlated to days of prophylaxis (LOS). The mean LOS decreased from 7.3 days in 2004 to 3.1 days in 2008. 3 deaths (0.15%) were associated with clotting episodes and overall, 11 clinical DVTs (0.56%) and 6 PEs (0.30%) were found. The vast majority of events took place within 30 days; only 1 death and 2 DVTs occurred between 30 and 90 days. During the last 2 years (854 patients), when patients were mobilized within 4 h postoperatively and the duration of DVT prophylaxis was shortest (1–4 days), the mortality was 0% (95% CI: 0–0.5). Incident cases of DVT in TKA was 0.60% (CI: 0.2–2.2), in THA it was 0.51% (CI: 0.1–1.8), and in BSTKA it was 0% (CI: 0–2.9). Incident cases of PE in TKA was 0.30% (CI: 0.1–1.7), in THA it was 0% (CI: 0–1.0), and in BSTKA it was 0% (CI: 0–2.9). The risk of clinical DVT, and of fatal and non-fatal PE after THA and TKA following a fast-track set-up with early mobilization, short hospitalization, and short duration of DVT prophylaxis compares favorably with published regimens with extended prophylaxis (up to 36 days) and hospitalization up to 11 days. This calls for a reconsideration of optimal duration of chemical thromboprophylaxis.
    Acta Orthopaedica 10/2010; 81(5):599-605. DOI:10.3109/17453674.2010.525196 · 2.77 Impact Factor
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    ABSTRACT: Fatal pulmonary thromboembolism is the most serious complication following surgery. Patients undergoing major orthopedic surgeries, including total hip replacement, total knee replacement, and hip fracture surgery, represent a group at particularly high risk of venous thromboembolism. Therefore, prophylaxis for thromboembolic events has been of great concern to surgeons. Edoxaban is a novel, orally available, and highly specific and direct factor Xa inhibitor. This new agent was approved for the prevention of venous thromboembolism in patients undergoing major orthopedic surgery, including total hip replacement, total knee replacement, and hip fracture surgery, by the Japanese Ministry of Health, Labor, and Welfare in 2011. Preclinical and Phase I clinical trials demonstrated several promising properties. Its rapid absorption and short life-time in blood are known. Edoxaban inhibits factor Xa activity directly and selectively. It also has a strong antithrombotic effect without any influence of food intake. Coagulation monitoring is not required. Edoxaban has predictable linear pharmacokinetic and pharmacodynamic profiles. Phase II and III clinical trials have been completed to examine its efficacy and safety in patients undergoing major orthopedic surgery. In these clinical trials, oral administration of edoxaban showed efficacy superior to that of oral placebo or subcutaneously administered dalteparin or enoxaparin. Edoxaban can be regarded as a first choice to prevent venous thromboembolism after major orthopedic surgery.
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