Venous thromboembolic disease after total hip and knee arthroplasty

A variety of pharmacologic and mechanical means can be used to prevent thromboembolic disease following total hip or knee arthroplasty. The existing pharmacologic options are parenteral heparin, fondaparinux, oral warfarin, and oral acetylsalicylic acid. An oral form of heparin as well as direct thrombin inhibitors of factors IIa, IXa, and Xa are being developed in the hope of discovering an agent that effectively prevents thrombi formation but carries a low risk of bleeding complications. Mechanical prophylaxis devices include foot pumps, calf pumps, and calf and thigh pumps for standard pneumatic compression, sequential compression, or rapid inflation compression. Although an ideal prophylaxis does not exist, a multimodal approach incorporating pharmacologic and mechanical prophylaxis has been proved safe and effective. The published recommendations of the American College of Chest Physicians (ACCP) for deep venous thrombosis prophylaxis of total joint patients are widely used throughout the world. These ACCP guidelines have a rigorous foundation in evidence-based medicine and meet the requirements of many oversight groups; some recommendations also meet the standards of certain state and federal programs. In the view of many orthopaedic surgeons, however, these ACCP guidelines have some notable disadvantages. The routine use of relatively aggressive pharmacologic prophylaxis has led to complication rates higher than those reported in the studies used by the ACCP. Equivalent results have been achieved in reducing symptomatic deep venous thrombosis, pulmonary embolisms, and deaths with less aggressive, less expensive prophylaxis protocols that still meet the requirements of recently enacted federal programs that monitor deep venous thrombosis.