The Multimodal Approach for the Prevention of Thromboembolic Disease After Total Joint Arthroplasty

Abstract

Total hip and knee arthroplasties carry an increased risk for thromboembolic disease. A multimodal prophylaxis protocol developed at the Hospital for Special Surgery and fully implemented since 1995, consists of stratifying the individual patient's risk and implementing a series of safe preventive measures before, during, and after surgery to reduce the risk of venous thromboembolism and bleeding. The measures include discontinuation of procoagulant medication and autologous blood donation before surgery; the use of hypotensive epidural anesthesia and intraoperative intravenous heparin after acetabular work during total hip arthroplasty; the use of pneumatic compression devices, elastic stockings, and frequent, vigorous dorsiflexion of the ankles; and prompt mobilization of the patient after surgery to diminish venous stasis. If these safe measures are observed, postoperative pharmacologic prophylaxis does not need to be aggressive in the patients without predisposing factors for venous thromboembolism and who mobilize promptly, thus diminishing the morbidity and mortality associated with the routine use of potent anticoagulants and the overall cost of care. Our clinical experience with close to 10,000 total hip and knee replacements demonstrates that this multimodal prophylaxis is safe and effective, resulting in a very low prevalence of thromboembolism, bleeding, and all-cause mortality.