Introduction. Pulmonary emboli (PE) after total hip and knee arthroplasties is an uncommon event. However, once it happens, it may results in sudden death. Thus, the prophylaxis of venous thromboembolism (VTE), including symptomatic deep vein thrombosis (DVT) and PE, is one of the challenging trials for Orthopaedic surgeons. Many procedures have been developed, e.g. early mobilization, compression stocking, intermittent pneumatic compression (IPC) devices, and anticoagulation agents. However, the most effective treatment for prophylaxis against VTE after the arthroplasties remains undecided. Recently, many low molecular weight heparin (LMWH) agents are developing, and these are strongly effective for anticoagulation. However, these agents sometimes lead to bleeding complications, and result in uncontrolled critical bleeding. We are introducing our protocol with conventional aspirin as VTE prophylaxis after the arithroplasties. Patients and methods. All patients prior to the surgeries are evaluated laboratory and duplex venous ultrasonography examinations to exclude thrombophilic or hemophilic conditions, and existence of DVT. Then, the thrombophilic, and also prolonged immobility, obesity, malignant tumors, cardiovascular dysfunction and DVT patients are regarded as high risk for VTE. These are offered a prophylaxis consisting of a removable inferior vena cava (IVC) filter, together with anticoagulant medication. Usually, the filter is removed three months after the surgery. In other patients, the arthroplasties are carried out under the spinal or epidural anesthesia with IPC on both feet. IPC is also applied, except for the periods of ambulation, usually two to three days of hospitalization after surgery. Full weight bearing ambulation with a walker is allowed on post-op day one. Patients receive aspirin (acetylsalicylic acid) 325 mg daily for six weeks starting the night of surgery. Pain is controlled with celecoxib (COX-2 selective nonsteroidal anti-inflammatory drug) 400 mg daily, and oral narcotics for break through pain. Before discharge, usually within three days post surgery, all patients are evaluated DVT by duplex venous ultrasonography. The incidence of blood loss, wound complications, and subcutaneous ecchymosis are recorded. Results and discussion. Although the incidence rate of all DVT (symptomatic and asymptomatic) after the arthroplasties was 2–3%, there was no patient readmitted or reoperated with critical bleeding, wound complications, nor fatal DVT/PE in this time period. The cost for the preoperative screening examinations, i.e. blood test and duplex venous ultrasonography, is approximately 200 US dollars. This is much less expensive than the cost associated with more aggressive anticoagulation agents and our procedures provided an acceptable level of outcomes with minimal risk of severe complications. Conclusions. The efficacy and safety of
Thromboembolic (TE) events and related wound issues are the most common post-operative complications related to lower extremity total joint arthroplasty. They represent not only significant morbidity but also serious economic consequences. Evolution has selected for thrombus formation as a protection against exsanguination. Trauma is by definition a thrombogenic event. As surgery is an elective trauma, it is understandable that an individual undergoing a surgical procedure will be at increased risk to develop a TE event. However, to treat all patients with an identical prophylaxis denies the reality that the population is not homogeneous. Rather it is a normal distribution with wide variability from hemophyllic to thrombophyllic. As a consequence some patients may be over treated with resultant wound complications, i.e. hematomas, drainage, delaying discharge or worse requiring re-admisssion, re-operation or worst of all a secondary infection of the implanted device. For this reason we proposed an inexpensive pre-operative screening protocol to more objectively identify an individual's levelof thrombophyllia. Although not exhaustive, it identifies those patients at ends of the curve with either an increased risk of clot or bleeding. It includes: Factor VIII, Factor V (Leyden), Factor C (APCR), Fibrinogen, D-dimer, Prothrombin Gene Mutation, ESR and CRP. This protocol costs less than $200/patient and was found to be 100% predictive of patient risk. Since instituting this protocol we have eliminated re-admission for complications related to overly aggressive TE prophylaxis. It has become an invaluable and intergral part of our pre-, intra- and post-operative protocol for
