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Guideline provides recommendations to reduce clots after hip, knee replacement
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An updated clinical practice guideline released recently by the American Academy of Orthopaedic Surgeons Board of Directors recommends how to reduce the likelihood of thromboembolic issues after hip or knee replacement surgery.
According to the new guideline, in the absence of prophylaxis, deep vein thrombosis (DVT) occurs in about 37% of patients, as detected by imaging. The guideline suggests use of preventive treatments and advises against routinely screening patients after surgery using ultrasound.
“Venous thromboembolic (VTE) disease is a well-known complication of hip and knee replacement, and it is something that all of us who perform this surgery do our best to avoid,” Joshua J. Jacobs, MD, American Academy of Orthopaedic Surgeons (AAOS) second vice president, told Orthopedics Today. “This particular guideline was an update of the first AAOS guideline on this issue … we want these guidelines on preventing VTE disease in hip and knee replacement patients to be current and of use to orthopedic surgeons caring for these patients.”
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In order for AAOS guidelines to be listed in the National Guideline Clearinghouse of the Agency for Healthcare Research and Quality (AHRQ), they need to be updated every 5 years. The previous AAOS guideline on this topic was posted in 2007.
Guideline recommendations
The guideline makes the following recommendations for preoperative hip or knee replacement care:
- Patients should stop taking antiplatelet medications as these increase the risk of intraoperative and postoperative blood loss;
- Physicians should discuss any prior history of DVT or pulmonary embolism, as this history is a risk factor for thromboembolic disease; and
- The use of regional anesthesia rather than general anesthesia should be discussed because while regional anesthesia has not been proven to affect the occurrence of DVT or PE, it limits blood loss.
The guideline also makes the following recommendations for postoperative hip or knee replacement care:
- As postoperative duplex ultrasonography screening does not significantly reduce the rate of DVT or PE, patients should not undergo this process;
- Anticoagulant therapy and/or mechanical compression devices should be administered following hip or knee replacement surgery. It was noted in the guideline, however, that there is “insufficient evidence to recommend any particular preventive strategy or the duration of these treatments”; and
- Patients should walk as soon as safely possible after hip or knee replacement. Although there is little evidence early mobilization reduces DVT rates, the guideline notes early mobilization is low cost and of minimal risk.
Gaps in the evidence
Jacobs cautioned that the guideline’s length should not be taken as an indication that the literature has provided a complete picture.
“Despite the fact that we have an over 800-page guideline, the literature we have available leaves us with less guidance than we would like,” he said.
Jacobs said an AAOS panel went through a process of defining critical outcomes they wanted to investigate in terms of VTE prophylaxis. Through an iterative Delphi process, they defined three critical outcomes: symptomatic PE, all-cause mortality and major bleeds.
“The evidence was analyzed for the impact of prophylactic protocols on those critical outcomes,” Jacobs said. “When you do that, it turns out the literature does not provide much guidance on the safest or most effective way to prevent VTE.”
Further suggestions by the workgroup that assembled the guideline include filling evidence gaps in the existent literature — a step deemed critical to develop the best possible strategies for the prevention of VTE.
“There are large gaps in the literature that do not allow us to provide as much guidance as we would like,” Jacobs concluded. “There is a need for further research in the area. Particularly, we need studies that are adequately powered to look at the relatively rare events of symptomatic PE, mortality and major bleeds.” – by Robert Press
References :
- Joshua J. Jacobs, MD, can be reached at Rush University Medical Center, 1725 Harrison St., No. 1063, Chicago, IL 60612; 312-432-2344; email: joshua.jacobs@rushortho.com.
- Disclosure: Jacobs is a paid consultant for Zimmer, Medtronic and Johnson & Johnson and receives research and institutional support from Arthrex, Biomet, Cervitech, DePuy, Johnson & Johnson, Medtronic, Medtronic Sofmor Danek, National Institutes of Health, Smith & Nephew, Spinal Motion, Stryker, Synthes, Tornier, Wright Medical Technology and Zimmer, and has stock options with Implant Protection.