Since the establishment of our department a multi-modal approach to thromboprophylaxis that uses aspirin for chemical prophylaxis was adopted. In accordance with the latest national recommendations, our routine chemical prophylaxis following arthroplasty was changed to rivaroxaban in 2012 and then dalteparin in 2013. This study aimed to compare venous thromboembolism (VTE) rates during the use of the aspirin-based protocol used from 2004 to 2011 with recent, rivaroxaban and dalteparin-based guidelines. Outcome data from ISD Scotland was retrieved and radiology reports performed for CT pulmonary angiograms and lower limb doppler ultrasound scans in our institution were assessed to identify cases of VTE following primary hip or knee arthroplasty. The incidence of pulmonary embolism (PE) and proximal deep venous thrombosis (DVT) was calculated for each year and compared using a Chi-squared test. Additionally, the change in extended thromboprophylaxis regimen was surveyed by recording the discharge prescriptions for consecutive arthroplasty patients for March every year. There were 90 radiologically confirmed cases of DVT or PE between 2004 and 2011 (incidence of 0.71%). The DVT/PE rate was subsequently 0.67% in 2012 and 0.69% in 2013, with a further 29 cases identified. This does not represent a significant change in the venous thromboembolism rates and remains below the national incidence of VTE (1.06%). Aspirin alone was used as chemical thromboprophylaxis in 80.8% of patients from 2004 to 2011, 50.9% in 2012, and 12.1% in 2013. The incidence of VTE at our centre remains favourable to national figures, but the modification of thromboprophylaxis guidelines will incur additional financial costs and has not had a significant reduction on the rate of VTE.
Rivaroxaban has been recommended for routine use as a thromboprophylactic agent in patients undergoing lower-limb arthroplasty. Starting January 2011, our unit has converted from aspirin to Rivaroxaban use routinely following lower-limb arthroplasty for venous thromboembolism (VTE) prophylaxis. The aim of this audit was to retrospectively review its efficacy and the morbidity associated with its use. All patients undergoing primary and revision lower-limb arthroplasty between February 2011 and July 2011 were reviewed. All patients undergoing total knee replacement surgery and total hip replacement surgery received oral rivaroxaban 10 mg daily post-operatively for 14 days and 35 days respectively. Outcome measures recorded were; investigation for DVT/PE, rate of DVT/PE, wound complications (infection, dehiscence, leaking, bleeding), blood transfusion rate and readmission rate within 6 weeks of surgery. Of the 162 patients identified, 19 were excluded due to insufficient information or because they did not receive rivaroxaban as VTE prophylaxis. 141 patients (mean age 71.7 years) were included. 69 primary and 5 revision total knee replacements were performed. 60 primary and 7 revision total hip replacements were performed. 9 patients (6.4%) underwent Doppler USS for a painful swollen leg with 1 (0.7%) DVT diagnosed. None were investigated for a pulmonary embolus. 25 (17.7%) patients developed wound complications: 10 superficial infections requiring oral antibiotics, 2 deep infections requiring theatre washout, 1 wound dehiscence, 5 continuously leaking wounds, 5 bleeding wounds/haematomas. 26 (18.4%) patients required post-operative blood transfusion (average 2.2 units). 12 (8.5%) patients were re-admitted within 6 weeks with post-op complications (6 wound complications, 5 painful/swollen limbs, 1 large per-vaginal bleed). In keeping with previous literature, the rate of VTE following lower-limb arthroplasty using rivaroxaban as prophylaxis is low. However, the rate of morbidity was higher when compared with the use of aspirin in our centre between April and September 2010.
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