The association between total hip arthroplasty and subsequent postoperative deep venous thrombosis is of particular concern because it can lead to symptomatic venous thromboembolic events. However, controversy remains about the optimal approach to prophylaxis. Some authors recommend the use of various chemoprophylactic agents, while others advocate the use of mechanical devices or combinations. The ideal method of prophylaxis should be effective and easy to administer, have a predictable onset and duration, have minimal interaction with food or other drugs, be easily reversible, be cost effective, and have a low risk of side effects. While available chemoprophylactic agents address some of these attributes, all have substantial drawbacks. Among the most concerning effects for orthopedic surgeons is the increased risk of bleeding and hematoma formation, which can be associated with periprosthetic infections. These typically lead to additional surgical procedures and significant patient morbidity, and can adversely impact clinical outcomes.
An alternative to chemoprophylaxis is the use of pneumatic intermittent compression devices. Modern compression devices are portable and easy to use, and have a high rate of patient compliance. Several studies have demonstrated the efficacy of these devices in reducing the risk of symptomatic venous thromboembolic disease, in some cases resulting in lower mortality when compared to pharmacological agents. Additionally, these devices significantly reduce the risk of postoperative bleeding.
The association between total hip arthroplasty (THA) and subsequent postoperative deep venous thrombosis (DVT) is well established, with an incidence as high as 54% reported in patients who do not receive any prophylactic anticoagulation.1 This is of particular concern because DVT may lead to serious symptomatic venous thromboembolic events such as pulmonary embolism, which in some patients can result in death. For this reason, the American Academy of Orthopaedic Surgeons guidelines recommend DVT prophylaxis following THA,2 although controversy remains about the optimal approach. While some authors and professional associations recommend the use of pharmacological prophylaxis, other groups believe that mechanical prophylaxis can be an equivalent, and sometimes a more optimal, solution.
The ideal method of DVT prophylaxis should be effective and easy to administer, have a predictable onset and duration, have minimal interaction with food or other drugs, be easily reversible, be cost effective, and have a low risk of side effects. A number of classes of pharmacological anticoagulants are currently available, including vitamin K antagonists such as warfarin; heparin and its fractionated derivatives; synthetic Factor Xa inhibitors such a fondaparinux; and direct thrombin inhibitors such as argatroban. While any 1 of these pharmaceuticals addresses several of the desirable attributes for a prophylactic treatment, each also has substantial drawbacks. For example, vitamin K antagonists require frequent monitoring of coagulation parameters that can be costly and difficult to administer outside of the hospital setting. In contrast, low-molecular-weight heparin requires daily injection either by the patient or a visiting caregiver.
While issues of cost and convenience are important in the context of the contemporary emphasis on cost control and patient-centered surgical practice, perhaps the greatest concern with currently available chemoprophylactic agents is the increased risk of postoperative bleeding. Anticoagulation necessarily increases the risk of bleeding that can result in hematoma formation in the vicinity of the recently exposed surgical site. Neviaser et al3 recently reported a 10% incidence of major bleeding with the use of low-molecular-weight heparin at therapeutic doses following total joint arthroplasty complicated by an in-hospital pulmonary embolism.
Hematoma formation has been significantly associated with the development of superficial surgical site infections following total joint arthroplasty (odds ratio=11.8; P=.001),4 which are highly correlated with deep wound infections that may require additional surgical procedures and potentially result in long-term reduction of clinical outcome for affected patients. Parvizi et al5 reported that patients who developed a periprosthetic infection following joint arthroplasty were >12 times as likely to have had a wound hematoma when compared to controls (P=.0001). In contrast, mechanical prophylaxis with compression devices does not alter coagulation parameters and thus has limited effect on the risk of bleeding.
Both chemoprophylactic agents and mechanical compression devices have been shown to reduce the incidence of deep venous thrombosis and symptomatic and fatal pulmonary embolism following total joint arthroplasty when compared to patients receiving no prophylaxis.6 However, while it has been postulated that the large majority of symptomatic pulmonary emboli originate from thrombi of the deep veins,7 other authors have reported that the majority of patients who develop a pulmonary embolism following total joint arthroplasty did not previously demonstrate DVT on duplex ultrasonography of the deep veins of the legs.8,9 Nevertheless, it is questionable whether chemoprophylactic agents provide any additional benefit over mechanical devices in reducing the incidence of symptomatic or fatal events despite the increased risk of bleeding. In addition, in a meta-analysis of 20 studies comparing the outcomes of different methods of thromboprophylaxis following total joint arthroplasty, Sharrock et al10 reported a significantly higher incidence of non-fatal pulmonary embolism (P=.04) and all-cause mortality (P<.01) in patients who received postoperative low-molecular-weight heparin or direct Factor Xa or thrombin inhibitors, when compared to patients treated with mechanical compression devices and aspirin.
Intermittent Pneumatic Compression Devices
An alternative to chemoprophylaxis in arthroplasty patients at standard risk for DVT is the use of pneumatic intermittent compression devices, sometimes in conjunction with acetylsalicylic acid. It has been postulated that in addition to the direct therapeutic action of reducing stasis in deep veins that can promote thrombosis,11 intermittent compression devices act indirectly by promoting the release of endothelial-derived factors that result in a fibrinolytic effect that may prevent DVT formation.12
While many different types of compression devices are available without standardized parameters for size, pressure, or frequency of compression, the American College of Chest Physicians guidelines note that there is Grade 1A evidence supporting their use in patients who have a high risk of bleeding.13 Agu et al14 reviewed the literature concerning the use of compression stockings for the prevention of DVT and reported that their use alone reduced the incidence of DVT by 57% following THA, with no difference in effectiveness seen between above or below the knee designs. In a randomized clinical trial, Pitto et al15 reported a 50% decrease in the incidence of DVT with the use of foot pumps compared to low-molecular-weight heparin following THA, although the study was insufficiently powered to detect differences in symptomatic events.
Historically, enthusiasm for the use of intermittent pneumatic compression devices has been limited because they tended to be uncomfortable and nonportable, limiting compliance and impairing patient mobilization. However, new devices have been developed that are lightweight, are powered by a rechargeable internal battery, and include built-in compliance monitoring. Recently, Colwell et al16 reported that the use of a new-generation compression device following total joint arthroplasty resulted in similar rates of venous thromboembolic disease (P=.953) when compared to patients treated with enoxaparin, while resulting in significantly lower incidence of bleeding events (0% vs 6%; P=.0004). Additionally, the patients used the device for a mean 83% of each 24-hour day, suggesting that the device is well tolerated during the daytime and when sleeping.
While the use of chemoprophylaxis following THA or total knee arthroplasty (TKA) is desirable due to the theoretical ease of administration, currently available agents may be associated with a relatively high rate of undesirable complications, specifically postoperative bleeding. In contrast, modern mechanical compression devices are often equally if not more effective in reducing mortality, are easy to use with high patient compliance, and have no bleeding complications. Overall, they appear to provide a greater number of desirable attributes when compared to currently available pharmacological treatments. For this reason, the use of mechanical devices is preferred for DVT prophylaxis following THA or TKA.
- Johnson R, Carmichael JH, Almond HG, Loynes RP. Deep venous thrombosis following Charnley arthroplasty. Clin Orthop Relat Res. 1978; (132):24-30.
- American Academy of Orthopaedic Surgeons. Clinical Guideline on Prevention of Pulmonary Embolism in Patients Undergoing Total Hip or Knee Arthroplasty. AAOS Web site. http://ww.aaos.org/Research/guidelines/PE_guideline.pdf. Published May 2007. Accessed May 16, 2010.
- Neviaser AS, Chang C, Lyman S, Della Valle AG, Haas SB. High incidence of complications from enoxaparin treatment after arthroplasty. Clin Orthop Relat Res. 2010; 468(1):115-119.
- Saleh K, Olson M, Resig S, et al. Predictors of wound infection in hip and knee joint replacement: results from a 20 year surveillance program. J Orthop Res. 2002; 20(3):506-515.
- Parvizi J, Ghanem E, Joshi A, Sharkey PF, Hozack WJ, Rothman RH. Does excessive anticoagulation predispose to periprosthetic infection? J Arthroplasty. 2007; 22(6 Suppl 2):24-28.
- Freedman KB, Brookenthal KR, Fitzgerald RH Jr, Williams S, Lonner JH. A meta-analysis of thromboembolic prophylaxis following elective total hip arthroplasty. J Bone Joint Surg Am. 2000; 82(7):929-938.
- Westrich GH, Rana AJ. Prevention and treatment of thromboembolic disease: an overview. Tech Orthop. 2001; 16(3):279-290.
- Della Valle CJ, Steiger DJ, DiCesare PE. Duplex ultrasonography in patients suspected of postoperative pulmonary embolism following total joint arthroplasty. Am J Orthop (Belle Mead NJ). 2003; 32(8):386-388.
- Jacovides CL, Bican O, Pour AE, Parvizi J, Rothman RH. Deep vein thrombosis: a good proxy for pulmonary embolus? Paper presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 9-13, 2010; New Orleans, Louisiana.
- Sharrock NE, Gonzalez Della Valle A, Go G, Lyman S, Salvati EA. Potent anticoagulants are associated with a higher all-cause mortality rate after hip and knee arthroplasty. Clin Orthop Relat Res. 2008; 466(3):714-721.
- Christen Y, Wütschert R, Weimer D, de Moerloose P, Kruithof EK, Bounameaux H. Effects of intermittent pneumatic compression on venous haemodynamics and fibrinolytic activity. Blood Coagul Fibrinolysis. 1997; 8(3):185-190.
- Comerota AJ, Chouhan V, Harada RN, et al. The fibrinolytic effects of intermittent pneumatic compression: mechanism of enhanced fibrinolysis. Ann Surg. 1997; 226(3):306-313.
- Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008; 133(6 Suppl):381S-453S.
- Agu O, Hamilton G, Baker D. Graduated compression stockings in the prevention of venous thromboembolism. Br J Surg. 1999; 86(8):992-1004.
- Pitto RP, Hamer H, Heiss-Dunlop W, Kuehle J. Mechanical prophylaxis of deep-vein thrombosis after total hip replacement a randomised clinical trial. J Bone Joint Surg Br. 2004; 86(5):639-642.
- Colwell CW Jr, Froimson MI, Mont MA, et al. Thrombosis prevention after total hip arthroplasty: a prospective, randomized trial comparing a mobile compression device with low-molecular-weight heparin. J Bone Joint Surg Am. 2010; 92(3):527-535.
Drs Zywiel, Johnson, and Mont are from the Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopaedics, Sinai Hospital of Baltimore, Maryland.
Drs Zywiel and Johnson have no relevant financial relationships to disclose. Dr Mont receives royalties from Stryker; is a consultant for Stryker and Wright Medical Technology, Inc; and has received research or institutional support from the National Institutes of Health (National Institute of Arthritis and Musculoskeletal and Skin Diseases & National Institute of Child Health and Human Development), Stryker, Tissue Gene, and Wright Medical Technology, Inc.
Presented at Current Concepts in Joint Replacement 2009 Winter Meeting; December 9-12, 2009; Orlando, Florida.
Orthopaedic Crossfire is a registered trademark of A. Seth Greenwald, DPhil(Oxon).
Correspondence should be addressed to: Michael A. Mont, MD, Rubin Institute for Advanced Orthopaedics, Center for Joint Preservation and Reconstruction, Sinai Hospital of Baltimore, 2401 W Belvedere Ave, Baltimore, MD 21215 (firstname.lastname@example.org; email@example.com).