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Prophylaxis
Thromboprophylaxis for total knee replacement
or total hip replacement surgery
Dr. Milind Patil
Joint Replacement Surgeon
Revival Bone and Joint Hospital, Thane
Introduction
Venous thromboembolism (VTE) is a serious
complication of orthopedic surgery. [1]
Low molecular weight heparin (LMWH) has been the
standard of care for thromboprophylaxis after total
knee replacement (TKR) or total hip replacement
(THR) surgery. [1]
However, direct oral anticoagulants (DOACs) are
increasingly being used as alternatives. [1]
International guidelines for
thromboprophylaxis
The most recent National Institute for health & Care
Excellence (NICE 2018) guidelines recommend
anticoagulation with rivaroxaban or LMWH after
total hip or knee arthroplasty. [2]
Both ACCP (2012) and American Society of
Hematology (ASH 2019) recommends extended
prophylaxis of 35 days and 19-42 days respectively
over short-term prophylaxis. [2, 3]
Extended thromboprophylaxis with
Rivaroxaban
The RECORD clinical trial program has earlier
established the better efficacy of rivaroxaban over
LMWH in VTE prevention post TKA/THA [4]
In addition, the extended use of rivaroxaban was
studied in a prospective trial enrolling 2,400 patients
after THA. [3]
Eight fewer symptomatic DVT per 1,000 was achieved
with rivaroxaban over LMWH after 34-day
prophylaxis. [3]
Pharmacotherapy
Opioid-prescribing practices after common
orthopaedic procedures
10 12 10 Dr Vivek Mittal Target areas for future initiatives
12
Incidence of DVT A quality improvement questionnaire study was
8 6 Orthopedic Surgeon
4 2 2 BLK Super Speciality Hospital, New Delhi conducted among orthopedic surgeons to assess the
0
potential opioid safety initiatives.
No prophylaxis LMWH Rivaroxaban prescribing practices and gain perspective on
[1]
Introduction
Fig: Incidence of DVT per 1000 patients after no prophylaxis and
thromboprophylaxis with LMWH and Rivaroxaban [3] The opioid prescribing practices can be improved by
Acute and chronic pain carries grave economic, developing training programs, increasing awareness,
Total mortality also reduced from 5 to 2 per 1,000 with operational, and personal consequences. [1]
rivaroxaban as compared to LMWH. [3] use of opioid tracking databases, and formulation of a
standardized recommended dose for common
Despite the guidelines promoting conservative pain [1]
Conclusion management, narcotic prescriptions have increased orthopedic surgeries.
by 51% and fatal opioid overdoses tripled over the last
6 years. [1] Clinical implication
For patients undergoing THA/TKA, the evidence is
strong and sufficient to conclude that
thromboprophylaxis with rivaroxaban is associated But, opioids are the mainstay of pain management The knowledge of opioid prescription variability and
following orthopedic surgery. [1] the prevailing opioid epidemic needs to be addressed
with better efficacy outcomes when compared with and resolved in the Indian scenario.
LMWH, without significant differences in major
bleeding and overall mortality. Therefore, to balance the benefits with the involved
risks the opioids should be judiciously prescribed. [1] This review can serve as an exemplar for the
References reevaluation of recommendations and institutional
practices to reduce excess postoperative opioid
1.Haykal T, Adam S, Bala A, et al. Thromboprophylaxis for Variability in Opioid-prescribing Practic- prescriptions.
orthopedic surgery; An updated meta-analysis. Thromb Res. es [2]
2021;199:43-53.
2.D.R. Anderson, G.P. Morgano, C. Bennett, F. Dentali, C.W. Level III observational cohort study evaluated the References
Francis, D.A. Garcia, et al., American Society of Hematology 2019 trends and variability in opioid prescriptions after
guidelines for management of venous thromboembolism: 1.Kopp, J. A., Anderson, A. B. et al. (2019). Orthopedic Surgeon
prevention of venous thromboembolism in surgical hospitalized common orthopedic procedures. Decision-Making Processes for Postsurgical Opioid Prescribing.
patients, Blood Adv 3 (23) (2019) 3898–3944. Military Medicine. Military Medicine, Vol. 185, March/April 2020
A retrospective study from 2015 and 2016
3.Y. Falck-Ytter, C.W. Francis, N.A. Johanson, C. Curley, O.E. Dahl,
2.Traven, Sophia A. MD; Brinton, Daniel L. PhD; Woolf, Shane K.
S. Schulman, et al., Prevention of VTE in orthopedic surgery Data on 73,921 subjects who underwent common
orthopaedic procedures MD; Leddy, Lee R. MD; Gottschalk, Michael B. MD; Slone, Harris S.
patients: antithrombotic therapy and prevention of thrombosis,
9th ed: American College of Chest Physicians Evidence- Based From Truven Health Market Scan database MD Notable Variability in Opioid-prescribing Practices After
Common Orthopaedic Procedures, Journal of the American
Clinical Practice Guidelines, Chest 141 (2 Suppl) (2012)
e278S–e325S. Academy of Orthopaedic Surgeons: March 1, 2021 - Volume 29 -
Initial opioid 90-day prescription Issue 5 - p 219-226.
(initial + refills)
prescription
4.Russell RD, Hotchkiss WR, Knight JR, Huo MH. The efficacy and
safety of rivaroxaban for venous thromboembolism prophylaxis
after total hip and total knee arthroplasty. Thrombosis.
2013;2013:762310. doi:10.1155/2013/762310 Median oral morphine equivalent and
Interquartile range were analyzed
Patients undergoing soft-tissue only precedures required
the fewest refills while patients undergoing
total joint arthroplasty required the most.
[Ref: 2]