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Hip Pelvis 2018; 30(4): 197-201

Published online December 31, 2018

https://doi.org/10.5371/hp.2018.30.4.197

© The Korean Hip Society

Deep Vein Thrombosis Prophylaxis after Total Hip Arthroplasty in Asian Patients

Jun-Shik Kim, MD

Author Affiliations
The Joint Replacement Center, Ewha Womans University Medical Center, Seoul, Korea

Correspondence to : Jun-Shik Kim, MD
(https://orcid.org/0000-0003-0340-4169)
The Joint Replacement Center, Ewha Womans University Medical Center, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul 07985, Korea
TEL: +82-2-2650-5905 FAX: +82-2-2650-5905
E-mail: kjsos@ewha.ac.kr

Received: May 22, 2018; Revised: July 18, 2018; Accepted: July 18, 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Go to

In Western patient populations, the reported incidence of imaging-demonstrated deep vein thrombosis (DVT) after total hip arthroplasty (THA) is as high as 70% without prophylaxis. The reported rates of symptomatic pulmonary embolism (PE) after THA in recent studies range from 0.6% to 1.5%, and the risk of fatal PE ranges from 0.11% to 0.19% in the absence of prophylaxis. Predisposing factors to DVT in western patients include advanced age, previous venous insufficiency, osteoarthritis, obesity, hyperlipidemia, dietary and genetic factors. However, Asian patients who have undergone THA have a strikingly low prevalence of DVT and virtually no postoperative PE. Some authors suggest low clinical prothrombotic risk factors and the absence of some DVT-related genetic factors in Asian patient populations decrease the risk of DVT, PE or both. In Korea, the prevalence of DVT after THA without thromboprophylaxis have ranges from 6.8% to 43.8%, and asymptomatic PE have ranges from 0% to 12.9%; there have been only two reported cases of fatal PE. Deep-wound infections resulting from postoperative hematomas or prolonged wound drainage have been reported with routine thromboprophylaxis. The prevalence of DVT differs varies based on patient ethnicity. Guidelines for the use of thromboprophylaxis were altered and focus on the potential value of outcomes compared with possible complications (e.g., bleeding).

Keywords Total hip arthroplasty, Deep vein thrombosis, Pulmonary embolism, Prophylaxis, Asians

MAIN DISCUSSION

Go to

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are serious complications after total hip arthroplasty (THA). In Western populations, the incidence of DVT after THA is reportedly as high as 70% without prophylaxis1). Recently reported rates of symptomatic PE after THA range from 0.6% to 1.5%, and the risk of fatal PE ranges from 0.1% to 0.19% without prophylaxis23).

Predisposing factors for DVT in Western patients include age over 60 years, previous venous insufficiency, obesity, dehydration, one or more comorbidities, hyperlipidemia, concomitant use of oral contraceptives, cancer, dietary factors, genetic factors and others4,56). On the contrary, Asian patients have a strikingly low prevalence of DVT and virtually no postoperative PE after THA7,8,910). Some authors have suggested that Asian populations have low clinical prothrombotic risk factors for DVT and the absence of some genetic factors involving in DVT9,511).

In Korea, the reported prevalence of DVT after THA without thromboprophylaxis ranges from 6.8% to 43.8%, and PE is reported to occur at rates between 0% and 12.9%-mostly asymptomatic. To date, only two cases of fatal PE have been reported1213). Routine use of thromboprophylaxis with anticoagulants has been associated with an increased rate of complications including deep-wound infection caused by postoperative hematoma or prolonged wound drainage.

This study aimed to explore the difference in DVT incidence rates between Asian and Western populations through a literature review and to identify updates to the guidelines for prevention of venous thromboembolism (VTE) to balance the relationship between prophylactic treatment and adverse drug events.

1. Prevalence of DVT and PE

Many publications have supported the use of prophylactic anticoagulant therapy because a decreased rate of DVT after THA can lower the incidence of PE, mortality and prevalence of postphlebitic syndrome14,1516).

Johnson et al.17) reported a prevalence of symptomatic PE after THA of 8% without thromboprophylaxis; there was a mortality rate of 1% associated with these cases of PE. Interestingly, the prevalence and mortality rates of PE have been reported to gradually decrease over time. Freedman et al.18) and Murray et al.19) reported that the rates of DVT after THA were similar irrespective of whether prophylatic treatment was provided. The prevalence of asympotmatic PE ranged from 12.6% to 18.9% and sympotmatic PE occurred only in 1.9% among patients who underwent THA. The rate of fatal PE ranged between 0% and 0.32% irrespective of prophylactic drug therapy1920).

2. Differences in the Prevalence of DVT and PE in Asians, Including Koreans

Asian patients have been reported to have a lower prevalence of DVT and PE after THA compared with Western patients8,10,21,22,2324). In the report by Klatsky et al.9), the prevalence of DVT and PE in Asian populations was estimated at 20% of the Western population.

Woo et al.25) noted that the incidence of PE among the Chinese population in Hong Kong was only 10% of the incidence rate observed within Western populations; those Chinese patients in Hong Kong with PE exhibited symptoms that were milder relative to those observed in Western populations.

In a study on DVT in Korean patients, the prevalence of DVT without thromboprophylaxis ranged from 6.8% to 43.8%, and Yoo et al.13) reported that symptomatic DVT rates were 8% and 20.7% in two different studies, respectively. The rate of asymptomatic PE was 12.9%. Hwang et al.12) and Yoo et al.13) reported a single case of symptomatic PE in each study, respectively. In both cases, the patient died. In the study published by Hwang et al.12), the patient received prophylactic dextran.

Kim et al.7) reported that the low prevalence of DVT and PE is attributable to low prevalence of venous disease, low obesity rate, low prevalence of hyperlipidemia, early postoperative exercise, and thrombosis mostly restricted to the veins of the lower limb. A low incidence of DVT and PE in Asian patients can be explained by variations in lifestyles, diet and genetic factors11,2627).

Westrich et al.5) stated the presence of the prothrombin G20210A gene mutation and a decreased antithrombin-III level were significantly correlated with the occurrence of PEs.

Salvati et al.28) reported that about 50% of patients with VTE after THA had heritable thrombophilia, indicating inherited deficiencies of antithrombin III and protein C or prothrombin gene mutations. Therefore, preoperative tests for these three genetic risk factors may help judge the degree of thromboprophylaxis.

Wåhlander et al.24) screened 1,600 patients and noted a tendency for increased risk of VTE and PE with the presence of a mutation in the prothrombin promoter region and factor V Leiden mutation.

Westrich et al.5) reported that the risk of developing PE reached almost 100% when antithrombin levels were lower than normal and the prothrombin promoter G20210A mutation was present.

Zivelin et al.6) identified that the prothrombin G20210A mutation led to elevated levels of factor II and was associated with a 2- to 5-fold increased risk for VTE; this mutation is present in 1% to 6% of the Caucasian population and rare in other populations.

According to Balasa et al.26), the prothrombin G20210A mutation is found in 4% to 6% of Caucasians and associated with an approximately 3-fold increased risk of VTE in persons with heterozygous forms of the mutation, and 20-fold risk in persons with homozygous inheritance.

3. Complications of Anticoagulant Thromboprophylaxis

Routine thromboprophylaxis-via administration of antithrombotic agents-may cause surgical wound hematomas, bleeding, skin necrosis, thrombophilia, or bleeding in the gastrointestinal tract or urinary system3,2728).

Parvizi et al.2930) reported that the use of low-dose warfarin or heparin may elevate the average international normalized ratio to 1.5 or higher and increase the risk of wound infections due to postoperative hematomas or prolonged wound drainage. Higher incidences of wound complications (e.g., hematomas or delayed wound drainage) occurred after intravenous administration compared with use of oral antithrombotic agents3132).

Patel et al.33) suggested an association between prolonged wound discharge with infections after THA and each day of prolonged wound drainage increased the risk of wound infection by 42%.

Although it is rare, the use of antithrombotic agents such as low molecular weight heparin can restrict regional anesthesia for prevention of spinal cord compression and paralysis following epidural hematoma or epidural catheterization for management of postoperative regional pain16).

4. Revised Guidelines for VTE Prevention

The American College of Chest Physicians (ACCP) published the guidelines for prevention of thrombosis in 1992, and it has since been updated. Thromboprophylaxis is strongly recommended for both THA and TKA in the ACCP guidelines. However, the new ACCP guidelines for prevention of thrombosis (9th edition, released in 2012) has focused on preventing symptomatic DVT and PE, and has restricted the use of prophylaxis in patients at a high risk of bleeding34).

In Journal of Arthroplasty in 2005, Callaghan et al.35) opined whether recommendations from the ACCP are appropriate for orthopaedic surgery. Since then, the American Association of Orthopaedic Surgeons (AAOS) developed its own thromboprophylaxis guidelines appropriate for orthopaedic surgery in 2007; an updated version published in 2011 consists of 10 recommendations classified as strong, moderate, weak, inconclusive and consensus based on the levels of evidence3536).

Considering the difference in prevalence of DVT and PE in Korean patients and adverse effects of anticoagulant drugs, the Korean Hip Society generated guidelines in 2011 for the use of DVT prophylaxis for both THA and hip fracture surgery according to DVT and bleeding risk factors4).

General recommendations are as follows:

  1. 1) All patients undergoing THA are recommended to be assessed preoperatively for risk of VTE and bleeding to choose appropriate VTE prophylaxis.
  2. 2) Regional anesthesia is recommended in consultation with anesthesiologists.
  3. 3) The use of anticoagulants should be stopped immediately in patients suspected of anticoagulant-related excessive bleeding.
  4. 4) All patients are recommended to ambulate as early as possible postoperatively for the prevention of VTE.
  5. 5) Patients and their family members are recommended to be educated about the clinical signs of VTE before discharge from the hospital and to visit the hospital immediately after the onset of these symptoms.

In cases of delayed surgery, the concurrent use of drug therapy and physical prophylaxis before surgery is strongly recommended in hip fracture patients at high risk of VTE in our aging society.

SUMMARY

Go to

DVT and PE-potential complications following THA-can be life-threatening, but fortunately, the reported prevalences of DVT and PE are low in Asians and Koreans because of relatively low obesity rates and serum lipid levels, and differences in ethnicity related genetic factors.

Considering complications of routine thromboprophylaxis (e.g., bleeding, hematoma, skin necrosis and infections), it would be more reasonable to use thromboprophylaxis depending on the individual needs of a patient (e.g., medical history and conditions), rather than following the guidelines for Western patients.

Anticoagulants for thromboprophylaxis cannot be easily used in many artificial joint patients who may experience complications due to routine use of thromboprophylaxis with anticoagulants, although not required, but only to avoid uncommon fatal PE.

Fortunately, the recommendations for VTE prophylaxis have been updated and the VTE prevention guidelines recommended by the Korea Hip Society are expected to serve as guidance for the appropriate treatment of Asian populations including Koreans.

REFERENCES

Go to
  1. Morris GK, Henry AP, Preston BJ. Prevention of deep-vein thrombosis by low-dose heparin in patients undergoing total hip replacement. Lancet 1974;2:797-800.
    Pubmed
  2. Fender D, Harper WM, Thompson JR, Gregg PJ. Mortality and fatal pulmonary embolism after primary total hip replacement. Results from a regional hip register. J Bone Joint Surg Br 1997;79:896-899.
    Pubmed
  3. Pellegrini VD, Clement D, Lush-Ehmann C, Keller GS, Evarts CM. The John Charnley Award. Natural history of thromboembolic disease after total hip arthroplasty. Clin Orthop Relat Res 1996;:27-40.
    Pubmed
  4. Park YS. Guideline for the prophylaxis of venous thromboembolism in hip surgery patients. J Korean Orthop Assoc 2011;46:95-98.
  5. Westrich GH, Weksler BB, Glueck CJ, Blumenthal BF, Salvati EA. Correlation of thrombophilia and hypofibrinolysis with pulmonary embolism following total hip arthroplasty: an analysis of genetic factors. J Bone Joint Surg Am 2002;84-A:2161-2167.
    Pubmed
  6. Zivelin A, Rosenberg N, Faier S, et al. A single genetic origin for the common prothrombotic G20210A polymorphism in the prothrombin gene. Blood 1998;92:1119-1124.
    Pubmed
  7. Kim YH, Oh SH, Kim JS. Incidence and natural history of deep-vein thrombosis after total hip arthroplasty. A prospective and randomised clinical study. J Bone Joint Surg Br 2003;85:661-665.
    Pubmed
  8. Kang BJ, Lee YK, Kim HJ, Ha YC, Koo KH. Deep venous thrombosis and pulmonary embolism are uncommon in East Asian patients after total hip arthroplasty. Clin Orthop Relat Res 2011;469:3423-3428.
    Pubmed
  9. Klatsky AL, Armstrong MA, Poggi J. Risk of pulmonary embolism and/or deep venous thrombosis in Asian-Americans. Am J Cardiol 2000;85:1334-1337.
    Pubmed
  10. Nandi P, Wong KP, Wei WI, Ngan H, Ong GB. Incidence of postoperative deep vein thrombosis in Hong Kong Chinese. Br J Surg 1980;67:251-253.
    Pubmed
  11. Kim YH, Kim JS. The 2007 John Charnley Award. Factors leading to low prevalence of DVT and pulmonary embolism after THA: analysis of genetic and prothrombotic factors. Clin Orthop Relat Res 2007;465:33-39.
    Pubmed
  12. Hwang DS, Kwon ST, Yune SH, Hong RO, Lee SY. Deep venoud thrombosis after hip arthroplasty. J Korean Orthop Assoc 1997;32:554-564.
  13. Yoo MC, Cho YJ, Yim CM, Hong GP, Kim JM. Deep vein thrombosis and pulmonary embolism after cementless total hip arthroplasty. J Korean Orthop Assoc 1998;33:1672-1680.
  14. Evarts CM, Feil EJ. Prevention of thromboembolic disease after elective surgery of the hip. J Bone Joint Surg Am 1971;53:1271-1280.
    Pubmed
  15. Paiement GD, Wessinger SJ, Hughes R, Harris WH. Routine use of adjusted low-dose warfarin to prevent venous thromboembolism after total hip replacement. J Bone Joint Surg Am 1993;75:893-898.
    Pubmed
  16. Thromboembolic Risk Factors (THRIFT) Consensus Group. Risk of and prophylaxis for venous thromboembolism in hospital patients. BMJ 1992;305:567-574.
    Pubmed
  17. Johnson R, Green JR, Charnley J. Pulmonary embolism and its prophylaxis following the Charnley total hip replacement. Clin Orthop Relat Res 1977;:123-132.
    Pubmed
  18. Freedman KB, Brookenthal KR, Fitzgerald RH, Williams S, Lonner JH. A meta-analysis of thromboembolic prophylaxis following elective total hip arthroplasty. J Bone Joint Surg Am 2000;82-A:929-938.
    Pubmed
  19. Murray DW, Britton AR, Bulstrode CJ. Thromboprophylaxis and death after total hip replacement. J Bone Joint Surg Br 1996;78:863-870.
    Pubmed
  20. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008;133:381S-453S.
    Pubmed
  21. Chau KY, Yuen ST, Wong MP. Clinicopathological pattern of pulmonary thromboembolism in Chinese autopsy patients: comparison with Caucasian series. Pathology 1997;29:263-266.
    Pubmed
  22. Chumnijarakij T, Poshyachinda V. Postoperative thrombosis in Thai women. Lancet 1975;1:1357-1358.
    Pubmed
  23. Tso SC, Wong V, Chan V, Chan TK, Ma HK, Todd D. Deep vein thrombosis and changes in coagulation and fibrinolysis after gynaecological operations in Chinese: the effect of oral contraceptives and malignant disease. Br J Haematol 1980;46:603-612.
    Pubmed
  24. Wåhlander K, Larson G, Lindahl TL, et al. Factor V Leiden (G1691A) and prothrombin gene G20210A mutations as potential risk factors for venous thromboembolism after total hip or total knee replacement surgery. Thromb Haemost 2002;87:580-585.
    Pubmed
  25. Woo KS, Tse LK, Tse CY, Metreweli C, Vallance-Owen J. The prevalence and pattern of pulmonary thromboembolism in the Chinese in Hong Kong. Int J Cardiol 1988;20:373-380.
    Pubmed
  26. Balasa VV, Gruppo RA, Glueck CJ, et al. The relationship of mutations in the MTHFR, prothrombin, and PAI-1 genes to plasma levels of homocysteine, prothrombin, and PAI-1 in children and adults. Thromb Haemost 1999;81:739-744.
    Pubmed
  27. Levine MN, Raskob G, Beyth RJ, Kearon C, Schulman S. Hemorrhagic complications of anticoagulant treatment: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126:287S-310S.
    Pubmed
  28. Salvati EA, Della Valle AG, Westrich GH, et al. The John Charnley Award: heritable thrombophilia and development of thromboembolic disease after total hip arthroplasty. Clin Orthop Relat Res 2005;441:40-55.
    Pubmed
  29. Parvizi J, Ghanem E, Joshi A, Sharkey PF, Hozack WJ, Rothman RH. Does “excessive” anticoagulation predispose to periprosthetic infection?. J Arthroplasty 2007;22:24-28.
    Pubmed
  30. Parvizi J, Kahl LK, Dalsey C. Aggressive anticoagulation after TJA: an evaluation of the ACCP guidelines for thromboprophylaxis. J Long Term Eff Med Implants 2007;17:359-365.
    Pubmed
  31. Colwell CW. Rationale for thromboprophylaxis in lower joint arthroplasty. Am J Orthop (Belle Mead NJ) 2007;36:11-13.
  32. Fitzgerald RH. Controversies in the prevention of deep vein thrombosis with total hip arthroplasty. Orthopedics 1994;17:8-10.
    Pubmed
  33. Patel VP, Walsh M, Sehgal B, Preston C, DeWal H, Di Cesare PE. Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty. J Bone Joint Surg Am 2007;89:33-38.
    Pubmed
  34. Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141:e278S-e325S.
    Pubmed
  35. Callaghan JJ, Dorr LD, Engh GA, et al. Prophylaxis for thromboembolic disease: recommendations from the American College of Chest Physicians--are they appropriate for orthopaedic surgery?. J Arthroplasty 2005;20:273-274.
    Pubmed
  36. Lieberman JR, Heckmann N. Venous thromboembolism prophylaxis in total hip arthroplasty and total knee arthroplasty patients: from guidelines to practice. J Am Acad Orthop Surg 2017;25:789-798.
    Pubmed

Article

Editorial

Hip Pelvis 2018; 30(4): 197-201

Published online December 31, 2018 https://doi.org/10.5371/hp.2018.30.4.197

Copyright © The Korean Hip Society.

Deep Vein Thrombosis Prophylaxis after Total Hip Arthroplasty in Asian Patients

Jun-Shik Kim, MD

The Joint Replacement Center, Ewha Womans University Medical Center, Seoul, Korea

Correspondence to:Jun-Shik Kim, MD
(https://orcid.org/0000-0003-0340-4169)
The Joint Replacement Center, Ewha Womans University Medical Center, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul 07985, Korea
TEL: +82-2-2650-5905 FAX: +82-2-2650-5905
E-mail: kjsos@ewha.ac.kr

Received: May 22, 2018; Revised: July 18, 2018; Accepted: July 18, 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

In Western patient populations, the reported incidence of imaging-demonstrated deep vein thrombosis (DVT) after total hip arthroplasty (THA) is as high as 70% without prophylaxis. The reported rates of symptomatic pulmonary embolism (PE) after THA in recent studies range from 0.6% to 1.5%, and the risk of fatal PE ranges from 0.11% to 0.19% in the absence of prophylaxis. Predisposing factors to DVT in western patients include advanced age, previous venous insufficiency, osteoarthritis, obesity, hyperlipidemia, dietary and genetic factors. However, Asian patients who have undergone THA have a strikingly low prevalence of DVT and virtually no postoperative PE. Some authors suggest low clinical prothrombotic risk factors and the absence of some DVT-related genetic factors in Asian patient populations decrease the risk of DVT, PE or both. In Korea, the prevalence of DVT after THA without thromboprophylaxis have ranges from 6.8% to 43.8%, and asymptomatic PE have ranges from 0% to 12.9%; there have been only two reported cases of fatal PE. Deep-wound infections resulting from postoperative hematomas or prolonged wound drainage have been reported with routine thromboprophylaxis. The prevalence of DVT differs varies based on patient ethnicity. Guidelines for the use of thromboprophylaxis were altered and focus on the potential value of outcomes compared with possible complications (e.g., bleeding).

Keywords: Total hip arthroplasty, Deep vein thrombosis, Pulmonary embolism, Prophylaxis, Asians

MAIN DISCUSSION

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are serious complications after total hip arthroplasty (THA). In Western populations, the incidence of DVT after THA is reportedly as high as 70% without prophylaxis1). Recently reported rates of symptomatic PE after THA range from 0.6% to 1.5%, and the risk of fatal PE ranges from 0.1% to 0.19% without prophylaxis23).

Predisposing factors for DVT in Western patients include age over 60 years, previous venous insufficiency, obesity, dehydration, one or more comorbidities, hyperlipidemia, concomitant use of oral contraceptives, cancer, dietary factors, genetic factors and others4,56). On the contrary, Asian patients have a strikingly low prevalence of DVT and virtually no postoperative PE after THA7,8,910). Some authors have suggested that Asian populations have low clinical prothrombotic risk factors for DVT and the absence of some genetic factors involving in DVT9,511).

In Korea, the reported prevalence of DVT after THA without thromboprophylaxis ranges from 6.8% to 43.8%, and PE is reported to occur at rates between 0% and 12.9%-mostly asymptomatic. To date, only two cases of fatal PE have been reported1213). Routine use of thromboprophylaxis with anticoagulants has been associated with an increased rate of complications including deep-wound infection caused by postoperative hematoma or prolonged wound drainage.

This study aimed to explore the difference in DVT incidence rates between Asian and Western populations through a literature review and to identify updates to the guidelines for prevention of venous thromboembolism (VTE) to balance the relationship between prophylactic treatment and adverse drug events.

1. Prevalence of DVT and PE

Many publications have supported the use of prophylactic anticoagulant therapy because a decreased rate of DVT after THA can lower the incidence of PE, mortality and prevalence of postphlebitic syndrome14,1516).

Johnson et al.17) reported a prevalence of symptomatic PE after THA of 8% without thromboprophylaxis; there was a mortality rate of 1% associated with these cases of PE. Interestingly, the prevalence and mortality rates of PE have been reported to gradually decrease over time. Freedman et al.18) and Murray et al.19) reported that the rates of DVT after THA were similar irrespective of whether prophylatic treatment was provided. The prevalence of asympotmatic PE ranged from 12.6% to 18.9% and sympotmatic PE occurred only in 1.9% among patients who underwent THA. The rate of fatal PE ranged between 0% and 0.32% irrespective of prophylactic drug therapy1920).

2. Differences in the Prevalence of DVT and PE in Asians, Including Koreans

Asian patients have been reported to have a lower prevalence of DVT and PE after THA compared with Western patients8,10,21,22,2324). In the report by Klatsky et al.9), the prevalence of DVT and PE in Asian populations was estimated at 20% of the Western population.

Woo et al.25) noted that the incidence of PE among the Chinese population in Hong Kong was only 10% of the incidence rate observed within Western populations; those Chinese patients in Hong Kong with PE exhibited symptoms that were milder relative to those observed in Western populations.

In a study on DVT in Korean patients, the prevalence of DVT without thromboprophylaxis ranged from 6.8% to 43.8%, and Yoo et al.13) reported that symptomatic DVT rates were 8% and 20.7% in two different studies, respectively. The rate of asymptomatic PE was 12.9%. Hwang et al.12) and Yoo et al.13) reported a single case of symptomatic PE in each study, respectively. In both cases, the patient died. In the study published by Hwang et al.12), the patient received prophylactic dextran.

Kim et al.7) reported that the low prevalence of DVT and PE is attributable to low prevalence of venous disease, low obesity rate, low prevalence of hyperlipidemia, early postoperative exercise, and thrombosis mostly restricted to the veins of the lower limb. A low incidence of DVT and PE in Asian patients can be explained by variations in lifestyles, diet and genetic factors11,2627).

Westrich et al.5) stated the presence of the prothrombin G20210A gene mutation and a decreased antithrombin-III level were significantly correlated with the occurrence of PEs.

Salvati et al.28) reported that about 50% of patients with VTE after THA had heritable thrombophilia, indicating inherited deficiencies of antithrombin III and protein C or prothrombin gene mutations. Therefore, preoperative tests for these three genetic risk factors may help judge the degree of thromboprophylaxis.

Wåhlander et al.24) screened 1,600 patients and noted a tendency for increased risk of VTE and PE with the presence of a mutation in the prothrombin promoter region and factor V Leiden mutation.

Westrich et al.5) reported that the risk of developing PE reached almost 100% when antithrombin levels were lower than normal and the prothrombin promoter G20210A mutation was present.

Zivelin et al.6) identified that the prothrombin G20210A mutation led to elevated levels of factor II and was associated with a 2- to 5-fold increased risk for VTE; this mutation is present in 1% to 6% of the Caucasian population and rare in other populations.

According to Balasa et al.26), the prothrombin G20210A mutation is found in 4% to 6% of Caucasians and associated with an approximately 3-fold increased risk of VTE in persons with heterozygous forms of the mutation, and 20-fold risk in persons with homozygous inheritance.

3. Complications of Anticoagulant Thromboprophylaxis

Routine thromboprophylaxis-via administration of antithrombotic agents-may cause surgical wound hematomas, bleeding, skin necrosis, thrombophilia, or bleeding in the gastrointestinal tract or urinary system3,2728).

Parvizi et al.2930) reported that the use of low-dose warfarin or heparin may elevate the average international normalized ratio to 1.5 or higher and increase the risk of wound infections due to postoperative hematomas or prolonged wound drainage. Higher incidences of wound complications (e.g., hematomas or delayed wound drainage) occurred after intravenous administration compared with use of oral antithrombotic agents3132).

Patel et al.33) suggested an association between prolonged wound discharge with infections after THA and each day of prolonged wound drainage increased the risk of wound infection by 42%.

Although it is rare, the use of antithrombotic agents such as low molecular weight heparin can restrict regional anesthesia for prevention of spinal cord compression and paralysis following epidural hematoma or epidural catheterization for management of postoperative regional pain16).

4. Revised Guidelines for VTE Prevention

The American College of Chest Physicians (ACCP) published the guidelines for prevention of thrombosis in 1992, and it has since been updated. Thromboprophylaxis is strongly recommended for both THA and TKA in the ACCP guidelines. However, the new ACCP guidelines for prevention of thrombosis (9th edition, released in 2012) has focused on preventing symptomatic DVT and PE, and has restricted the use of prophylaxis in patients at a high risk of bleeding34).

In Journal of Arthroplasty in 2005, Callaghan et al.35) opined whether recommendations from the ACCP are appropriate for orthopaedic surgery. Since then, the American Association of Orthopaedic Surgeons (AAOS) developed its own thromboprophylaxis guidelines appropriate for orthopaedic surgery in 2007; an updated version published in 2011 consists of 10 recommendations classified as strong, moderate, weak, inconclusive and consensus based on the levels of evidence3536).

Considering the difference in prevalence of DVT and PE in Korean patients and adverse effects of anticoagulant drugs, the Korean Hip Society generated guidelines in 2011 for the use of DVT prophylaxis for both THA and hip fracture surgery according to DVT and bleeding risk factors4).

General recommendations are as follows:

  1. 1) All patients undergoing THA are recommended to be assessed preoperatively for risk of VTE and bleeding to choose appropriate VTE prophylaxis.
  2. 2) Regional anesthesia is recommended in consultation with anesthesiologists.
  3. 3) The use of anticoagulants should be stopped immediately in patients suspected of anticoagulant-related excessive bleeding.
  4. 4) All patients are recommended to ambulate as early as possible postoperatively for the prevention of VTE.
  5. 5) Patients and their family members are recommended to be educated about the clinical signs of VTE before discharge from the hospital and to visit the hospital immediately after the onset of these symptoms.

In cases of delayed surgery, the concurrent use of drug therapy and physical prophylaxis before surgery is strongly recommended in hip fracture patients at high risk of VTE in our aging society.

SUMMARY

DVT and PE-potential complications following THA-can be life-threatening, but fortunately, the reported prevalences of DVT and PE are low in Asians and Koreans because of relatively low obesity rates and serum lipid levels, and differences in ethnicity related genetic factors.

Considering complications of routine thromboprophylaxis (e.g., bleeding, hematoma, skin necrosis and infections), it would be more reasonable to use thromboprophylaxis depending on the individual needs of a patient (e.g., medical history and conditions), rather than following the guidelines for Western patients.

Anticoagulants for thromboprophylaxis cannot be easily used in many artificial joint patients who may experience complications due to routine use of thromboprophylaxis with anticoagulants, although not required, but only to avoid uncommon fatal PE.

Fortunately, the recommendations for VTE prophylaxis have been updated and the VTE prevention guidelines recommended by the Korea Hip Society are expected to serve as guidance for the appropriate treatment of Asian populations including Koreans.

References

  1. Morris GK, Henry AP, Preston BJ. Prevention of deep-vein thrombosis by low-dose heparin in patients undergoing total hip replacement. Lancet 1974;2:797-800.
    Pubmed
  2. Fender D, Harper WM, Thompson JR, Gregg PJ. Mortality and fatal pulmonary embolism after primary total hip replacement. Results from a regional hip register. J Bone Joint Surg Br 1997;79:896-899.
    Pubmed
  3. Pellegrini VD, Clement D, Lush-Ehmann C, Keller GS, Evarts CM. The John Charnley Award. Natural history of thromboembolic disease after total hip arthroplasty. Clin Orthop Relat Res 1996;:27-40.
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Vol.36 No.1 Mar 01, 2024, pp. 1~75
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