The pathogenesis and prevention of thromboembolic complications in patients undergoing total hip replacement

Abstract

A 1987 survey of U.S. orthopedic surgeons found that 84% used some form of DVT prophylaxis. Ten percent used prophylaxis only for their "high-risk patients," and 6% never used prophylaxis. Twenty percent of the surgeons had at least one THR patient die from a fatal PE in the last five years. Fifty percent of the surgeons using warfarin had subsequently discontinued its use because of bleeding complications and monitoring difficulties. Compared with a survey done 13 years previously, this recent study showed a dramatic rise in the number of surgeons using DVT prophylaxis. The majority, however, were using methods that are ineffective: 67% used aspirin and 17% used fixed doses of subcutaneous heparin. Because the incidences of DVT and PE in THR patients are high, all of these patients should receive prophylaxis. The standard LDH regimen, effective for patients receiving gynecologic, general, and most orthopedic procedures, is ineffective for THR patients. The available prophylactic methods proven to reduce DVT and PE in THR patients are adjusted-dose subcutaneous heparin, dextrans, low-dose warfarin, and EPC. Comparative studies have not clearly demonstrated superiority of any one method. However, low-dose warfarin may offer better protection in very high-risk patients. External pneumatic compression offers protection without increasing bleeding risks. Dextrans are effective but are expensive and may be associated with significant side effects. Adjusted-dose subcutaneous heparin is also effective but is cumbersome to use. Low-molecular-weight heparin appears to be a promising alternative. We recommend the routine use of EPC and reserve low-dose warfarin fro patients with histories of prior thromboembolic or venous disease.(ABSTRACT TRUNCATED AT 250 WORDS)