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General Orthopaedics


Current Concepts in Joint Replacement (CCJR) – Spring 2015


Our American Academy of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP) have come to a consensus that the use of routine prophylaxis against venous thromboembolism (VTE) is indicated for our patients undergoing total joint arthroplasty. The new guidelines acknowledge differences in efficacy of the various agents and the variable risk of VTE among patients. Agents include warfarin, low molecular weight heparin, aspirin, oral Xa inhibitors, and direct thrombin inhibitors. The use of pneumatic compression devices have been found to be effective in decreasing risk of deep vein thrombosis (DVT) as a stand-alone strategy after total knee arthroplasty (TKA) and is given a level 1C recommendation by ACCP while the data is less strong for use following total hip arthroplasty (THA). Mechanical devices are not associated with an increased bleeding risk, and address the concerns of some surgeons with regard to post-operative bleeding. The availability of mobile compression devices has expanded the indications for use as a result of portability.

While the use of mobile pump technology in DVT prophylaxis adds to the armamentarium of tools available for use in VTE risk mitigation, it does not eliminate the need for pharmacologic prophylaxis. While all arthroplasty patients are at elevated risk of VTE, the highest risk is associated with those having a prior history of DVT or pulmonary embolism (PE), having had prior surgery within the preceding three months, or requiring prolonged immobilization post-operatively for any reason. In these patients, thromboprophylaxis with any of a number of agents will play a valuable role in VTE risk reduction. Additionally, not all patients tolerate the use of the pump device. Those individuals with chronic peripheral arterial disease or arterial ulcers in the legs are also poor candidates for mechanical compression strategies which may exacerbate existing vascular compromise and perfusion of the limb. Assessment of the medical comorbidities of the patient may also stratify them to higher risk where the demonstrated benefits of pharmacologic prophylaxis outweigh the considerations of bleeding associated with their use (such as in the morbidly obese/high BMI patients).

Mobile pump technology is a valuable adjunct to our VTE reduction strategies, but do not eliminate the need for pharmacologic agents. The judicious selection of DVT prophylaxis strategies based on the totality of the constellation of orthopaedic and medical factors unique to each patient allows us to make clinical decisions tailored to their needs, their risk of VTE, and their reliability in functioning as an active partner in their own post-operative care.