[Antithrombotic prophylaxis after THA and TKA: the surgeon's point of view]

Total hip arthroplasty (THA) and total knee arthroplasty (PTG) are surgical interventions aiming at functional improvement. They therefore cannot accommodate any "collateral damage" produced, notably by symptomatic thromboembolic events (STE). Use of the necessary thromboprophylaxis has made STEs rare (<3% after THA and 2% after TKA). Pulmonary embolism (PE) is exceptional (0.3%) and only accounts for 15% of the deaths occurring in the 1st postoperative month. However, atherothrombotic disease is significantly associated with thromboembolic venous disease. The causes of STEs are mechanical, directly related to surgical maneuvers, but also biological (familial or acquired thrombophilia, hypercoagulability, particularly associated with hip surgery). Delayed resumption of walking, which promotes venous stasis, has been improved by modern pain management techniques. There is consensus on the need to prolong thromboprophylaxis after THA, but it is more controversial after TKA and depends on the added risk factors. In France, prolonged prevention is widespread. The relatively low STE rate should be put into perspective with the risk of hemorrhage. The surgeon should be particularly attentive to the risk of bleeding at the operative site because it generates a risk of sepsis, and a risk of stiffness for TKA. The risk of hemorrhage essentially results from the misuse of all the anticoagulants, particularly observed with the anti-vitamin K medications because their use is more restricted. The risk of hemorrhage has become quite comparable to the risk of thromboembolism with prophylaxis. To prevent this event, the prescriber must know the characteristics of each drug : Tmax, half-life, mode of elimination, as well as the risk of accumulation in the patient receiving such treatment (creatinine clearance). Currently, the thrombohemorrhagic risk for each patient must be assessed. Per os treatment with Dabigatran etexilate is highly advantageous because it is easy to use, there is no thrombopenia induced by heparin, and there is no need for complementary monitoring exams, thus reducing costs. Efficacy in terms of prevention and hemorrhagic risk, demonstrated in phase II studies, must be confirmed by widespread used in real-life conditions.