Thromboprophylaxis following hip and knee arthroplasty

Abstract

Aim To determine local thromboprophylaxis prescribing practices following arthroplasty. Methods A retrospective review was performed of 300 consecutive hip and knee arthroplasty patients (150 each) over a 2‐year period at Tasmania's major public hospital. The provision of thromboprophylaxis, the presence of bleeding/thrombotic risk factors and the prevalence of symptomatic venous thromboembolism (VTE) and major bleeding occurring within 90 days postoperatively were documented. Results The mean age of the 300 patients (169 females, 131 males) was 68.7 years (standard deviation 10.4). Only 11.3% of knee arthroplasty and 16.7% of hip arthroplasty inpatients had mechanical thromboprophylaxis documented during their stay. All inpatients received pharmacological thromboprophylaxis, predominantly injectable anticoagulants (98.4%). Only 36.5% continued to receive pharmacological thromboprophylaxis following discharge, predominantly an antiplatelet agent (55.5%). The 90‐day incidence of symptomatic VTE was 2.7% (95% confidence interval: 1.0–5.0%); 4.0% (95% confidence interval: 1.0–8.0%) for knees and 1.3% (95% confidence interval: 0–5.0%) for hips. The in‐hospital and post‐discharge VTE incidence was 0.7% and 2.0% respectively. All readmissions for VTE occurred within 1 month of surgery. Conclusions While inpatient thromboprophylaxis was routine, it generally was not continued on discharge, potentially leaving many patients exposed to a higher risk of VTE. Most cases of symptomatic VTE occurred after discharge, with the majority requiring readmission to hospital under medical units.Within the limitations of a retrospective study, these findings suggest a need for further research and discussion regarding what constitutes appropriate thromboprophylaxis (type, agent and duration) following hip or knee arthroplasty.

Thromboprophylaxis in patients undergoing total hip and knee arthroplasty: a review of current practices in an Australian teaching hospital

“…Less commonly encountered reasons included prescription of subtherapeutic dose (4%, 4/101) and prescription of an agent not recommended for thromboprophylaxis (1%, 1/101). This is consistent with previous reports where inadequate duration of chemoprophylaxis was a commonly cited reason for poor adherence to accepted guidelines . It is recognised that the risk of VTE extends beyond the period of hospitalisation and in our study, 25.8% (98/380) of patients received no chemoprophylaxis on discharge, suggesting that re‐assessment of duration of chemoprophylaxis prescription represents an area of potential improvement.…”

“…Previous Australian studies have reported that mechanical thromboprophylaxis continues to be underused . A recent study evaluating patients undergoing TKA and THA at an Australian public hospital revealed that over 60% of patients did not receive any form of documented thromboprophylaxis on discharge, and only 35% received chemoprophylaxis on discharge . The results of our study show a higher proportion of patients receiving prophylaxis on discharge, with 74.5% (283/380) of eligible patients receiving chemoprophylaxis on discharge.…”

“…Suboptimal thromboprophylaxis prescription has been described internationally; a large study of patients undergoing orthopaedic surgery across the USA found that almost 50% of patients did not receive guideline recommended thromboprophylaxis . Previous Australian studies have reported that mechanical thromboprophylaxis continues to be underused . A recent study evaluating patients undergoing TKA and THA at an Australian public hospital revealed that over 60% of patients did not receive any form of documented thromboprophylaxis on discharge, and only 35% received chemoprophylaxis on discharge .…”

“…Thromboprophylaxis significantly reduces the rate of VTE post‐operatively with an acceptable level of adverse effects . Despite this, recent studies have demonstrated suboptimal use of thromboprophylaxis in several patient groups, including those undergoing major orthopaedic surgery …”

Intermittent pneumatic compression is a cost-effective method of orthopedic postsurgical venous thromboembolism prophylaxis

“…Rates of VTE after total knee arthroplasty (TKA) and total hip arthroplasty (THA) have been reported to be between 40 and 94 and 13 and 24 per 1,000 patients, respectively. 7 – 9 With an aging population, the overall incidence and impact of VTE after arthroplasty are expected to increase substantially over the next few decades. For instance, the number of THA and TKA procedures have been increasing at 3.7% and 7.0% per year in Australia.…”