Natural History
Insall 1984 / no prophylaxis
- DVT 70 - 80%
- asymptomatic PE 8 -17%
- symptomatic PE 0.5 -3%
- death 0.2%
- most commonly in calf / 85-90% below trifurcation
THR
- THR only 10-15% below trifurcation
Bilateral DVT in 10-15%
Prophylaxis
Mechanical prophylaxis
- TEDS
- compression stockings
- early mobilisation
Chemical prophylaxis
- LMWH / enoxaparin
- factor Xa (oral) / rivaroxaban
With appropriate prophylaxis
- symptomatic DVT 1/10 or less
- symptomatic PE 1 or 2 / 100
- fatal PE 1 / 1000
Results
Brookenthal et al J Arthroplasty 2001
- meta-analysis
- LMWH better than warfarin at preventing proximal DVT
- no significant difference in LMWH / warfarin / aspirin in reducing symptomatic or fatal PE
- no significant difference in bleeding rates
Edwards et al J Arthroplasty 2008
- RCT of LMWH v LMWH + compression stocking
- significant reduction in DVT rates
- RCT 100mg aspirin v 40 mg enoxeparin / LMWH in 9711 THA and TKA patients
- symptomatic VTE in aspirin group was 3.5%
- symptomatic VTE in enoxeparin group was 1.8%
- no difference in mortality
Lassen MR, Ageno W, Borris LC, Lieberman JR, Rosencher N, Bandel TJ, Mis-
selwitz F, Turpie AG; RECORD3 Investigators. Rivaroxaban versus enoxaparin for
thromboprophylaxis after total knee arthroplasty. N Engl J Med. 2008 Jun 26;
358(26):2776-86.
Turpie AG, Lassen MR, Davidson BL, Bauer KA, Gent M, Kwong LM, Cushner FD,
Lotke PA, Berkowitz SD, Bandel TJ, Benson A, Misselwitz F, Fisher WD; RECORD4
Investigators. Rivaroxaban versus enoxaparin for thromboprophylaxis after total
knee arthroplasty (RECORD4): a randomised trial. Lancet. 2009 May 16;373(9676):
1673-80. Epub 2009 May 4
Lassen MR, Raskob GE, Gallus A, Pineo G, Chen D, Hornick P; ADVANCE-2
investigators. Apixaban versus enoxaparin for thromboprophylaxis after knee
replacement (ADVANCE-2): a randomised double-blind trial. Lancet. 2010 Mar 6;
375(9717):807-15.