Management Of Deep Venous Thromboembolism (DVT) After Total Joint Replacement

In the absence of thromboprophylaxis,venous thromboembolism(VTE)affects about 50 to 80%of the patients after total hip replacement(THR),total knee replacement(TKR),or hip fracture surgery.Since stratification of patients in those who will become symptomatic and those who will not,is not possible,primary high risk thromboprophylaxis should be provided to all patients undergoing major orthopedic surgery of the lower extremity.Patients undergoing major orthopedic surgery of the lower extremities belong to a very high risk group for VTE and are candidates for high risk thromboprophylaxis.Thromboprophylaxis with LMWH(～5000 IU s.c.daily)is recommended for patients with THR.Alternatively,vitamin K-antagonists(target INR 2.0-3.0)can be given.Patients undergoing TKR should receive LMWH thromboprophylaxis(～5000 IU s.c.daily).In general,prophylactic interventions are less effective in these patients,and DVT rates remain high despite primary thromboprophylaxisAfter hip fracture surgery,LMWH thromboprophylaxis(～5000 IU s.c.daily)should be given to all patients.Alternatively,vitamin Kantagonists(target INR 2.0-3.0)can be given Thromboprophylaxis should be started 2 hours preoperatively or 6 to 8 hours postoperatively The use of acetylsalicylic acid for thromboprophylaxis in patients undergoing major orthopedic surgery of the lower extremities is not recommended,as other measures are more efficacious Adjuvant prophylaxis with elastic stockings or intermittent pneumatic compression may have additional benefit.The optimal duration of anti coagulation in patients after THR or TKR is uncertain.Extended thromboprophylaxis(beyond 7 to 10 days after surgery)is recommended for highrisk patients.In patients with hip fracture,thromboprophylaxis should be continued until the patient is ambulatory.Fondaparinux or(xi)melagatran is associated with a significantly reduced relative risk of asymptomatic VTE compared to LMWH(enoxaparin).The incidence of symptomatic VTE is not reduced by these new antithrombotics compared with LMWH.In addition,an increased bleeding risk during fondaparinux or(xi)melagatran prophylaxis is observed.In the light of other potential side effects[e.g.,elevation of transaminases in case of(ⅹⅰ)melagatran]and high costs the role of these new antithrombotics in the prophylaxis of VTE in patients undergoing major orthopedic surgery of the lower extremities remains to be established.