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Carefully consider the use of long-term thromboprophylaxis following TJR surgery
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by Per Kjaersgaard-Andersen, MD
Clinical deep vein thrombosis prophylaxis has gained major interest globally as a needed and demanded treatment within several surgical and nonsurgical circumstances. The most feared major clinical complications of deep vein thrombosis that make prophylaxis treatment necessary are chronic venous insufficiency following clotting of the deep veins and sudden death after pulmonary embolism.
As orthopaedic surgeons, we are continuously reminded that treatment must be started as early as possible — with recent recommended approaches beginning days before surgery and lasting for several weeks after surgery. In addition, instructing our patients and ensuring their compliance has become much easier since the introduction of new oral prophylaxis drugs, compared with a daily injection.
In my clinic we start treatment on the day of surgery and continue treatment for up to 7 days, depending on length of hospital stay and recognized high-risk factors. However, the question for us as orthopaedic surgeons performing major orthopaedic joint replacement surgery is whether our patients really need long-term treatment — or even more controversial, whether they all need to be treated?
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Fast-track procedures
We have clinical guidelines stating that prophylaxis is mandatory for major surgery such as joint replacement. Therefore, all of our patients are treated with prophylaxes. However, modern total joint replacement units mobilize their patients within hours after surgery, even instructing them to walk several hours on the first day after surgery as part of a fast-track rehabilitation program. Unfortunately, there is no literature on deep vein thrombosis (DVT) and pulmonary embolism (PE) incidences in fast-track patients, as all DVT and PE literature are based on patients being immobilized for several days following their procedures.
The short-term treatment has been part of my clinic’s program for several years. We have observed no increased incidence of DVT or PE during the past 8 years, during which we have reduced our in-hospital stay for both total hip and knee replacements from an average of 11 days to 2.8 days.
Conservative measures
During the last decade we stayed on our original low-molecular-weight heparin (Klexane, Sanofi-Aventis) starting before surgery. We have therefore been conservative and have not introduced the new oral drugs.
To the best of my knowledge, as any medical treatment has both benefits and side-effects, one must make an overall conclusion, based not only on evidence from other groups of patients but also on the risk to the patient being treated while also considering the effects on the health care economy of treating all joint replacement patients for several weeks.
Therefore, I recommend that my colleagues take a conservative approach to introducing long-lasting DVT prophylaxis, and I ask the larger clinics that perform several joint replacements per year, together with the industry, to undertake studies involving these new early-mobilized joint replacement patients so that our scientific knowledge may be increased to better meet their needs for prophylaxes.