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Management of Deep Vein Thrombos in Total Joint Arthroplasty Total Hip and Knee Symposium Los Cabos, Mexico.

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Presentation on theme: "Management of Deep Vein Thrombos in Total Joint Arthroplasty Total Hip and Knee Symposium Los Cabos, Mexico."— Presentation transcript:

1 Management of Deep Vein Thrombos in Total Joint Arthroplasty Total Hip and Knee Symposium Los Cabos, Mexico

2 Frank R. Ebert, MD Assistant Chief Department of Orthopædics The Union Memorial Hospital Baltimore, Maryland

3 Number of Orthopedic Replacement Procedures/Year Total knee replacements:267,000/year in the US Total knee replacements:267,000/year in the US Total hip replacements:more than 168,000/year in the US Total hip replacements:more than 168,000/year in the US AAOS Website availiable at:

4 The Cost of DVT Risk persists for a long time following surgery. Risk persists for a long time following surgery. 90% of medical re-admissions following TJR are due to DVT; substantial direct inpatient costs related to DVT 90% of medical re-admissions following TJR are due to DVT; substantial direct inpatient costs related to DVT

5 Venous Thromboembolism: Pathogenesis Venousthrombi Venousthrombi Usually form in regions of sluggish or altered flow in large venous sinuses Usually form in regions of sluggish or altered flow in large venous sinuses May break off, travel to lung – PE May break off, travel to lung – PE Pathogenic factors Pathogenic factors Activation of blood coagulation Activation of blood coagulation Venous stasis Venous stasis Vascular injury Vascular injury

6 Venous Thromboembolism: Natural History Hip Procedures Hip Procedures Have a higher frequency of proximal clots Have a higher frequency of proximal clots Knee Procedures Knee Procedures Deep calf veins Deep calf veins Usually asymptomatic Usually asymptomatic Thrombi tend to be small Thrombi tend to be small Propagation is an issue Propagation is an issue

7 Venous Thromboembolism: Natural History (cont’d) Proximal vein thrombi Proximal vein thrombi Popliteal Popliteal Superficial femoral Superficial femoral Common femoral Common femoral Iliac veins Iliac veins Spontaneous lysis of large thrombi uncommon Spontaneous lysis of large thrombi uncommon Strong association between DVT and PE Strong association between DVT and PE

8 Venous Thromboembolism: Diagnosis Clinical Exam 50/50 Clinical Exam 50/50 Venous duplex ultrasound Venous duplex ultrasound Venography Venography

9 Venous Thromboembolism: Diagnosis (cont’d) Venous duplex ultrasound Venous duplex ultrasound Noninvasive Noninvasive Assesses vein compressibility Assesses vein compressibility Very sensitive in proximal thrombi Very sensitive in proximal thrombi Less sensitive in distal Less sensitive in distal

10 Venous Thromboembolism: Diagnosis (cont’d) Venography Venography FDA standard for DVT FDA standard for DVT Clinically outmoded Clinically outmoded

11 Pulmonary Embolism: Diagnosis Screening Screening V/Q scan V/Q scan Effective non-invasive technique Effective non-invasive technique Probability of PE based on degree of mismatch between ventilation and perfusion Probability of PE based on degree of mismatch between ventilation and perfusion

12 Pulmonary Embolism: Diagnosis (cont’d) Definitive test Definitive test Pulmonary angiogram Pulmonary angiogram Spiral CT Spiral CT

13 Hirsh J, Hoak J. Circulation. 1996;93:2213. Venous Thromboembolism: Prognosis Proximal DVT: postoperative, good, if treated for 3 months with anticoagulant therapy Proximal DVT: postoperative, good, if treated for 3 months with anticoagulant therapy Recurrent events: 5% Recurrent events: 5% After discontinuation of anticoagulant therapy: After discontinuation of anticoagulant therapy: 5% to 10% after 1 year 5% to 10% after 1 year Approximately 30% after 8 years Approximately 30% after 8 years

14 Anderson FA Jr, Wheeler HB. Clin Chest Med. 1995;16:236. Clinical Risk Factors for DVT Major surgery (eg, total joint arthroplasty) Major surgery (eg, total joint arthroplasty) History of DVT History of DVT Age ≥40 Age ≥40 Obesity Obesity Prolonged immobility Prolonged immobility Genetic predisposition to hematologic abnormalities Genetic predisposition to hematologic abnormalities Trauma Trauma Other: malignancy, coronary syndromes (eg, unstable angina) Other: malignancy, coronary syndromes (eg, unstable angina)

15 *DVT prevalence statistics obtained by use of mandatory postoperative venography. † Represents the upper limit of prevalence statistics for each procedure. Geerts WH, et al. Chest. 2001;119(suppl):140S All DVTProximal DVTFatal PE Hip arthroplasty Knee arthroplasty Hip fracture surgery % of patients* † 57% 84% 60% 36% 20% 36% 0.4% 0.7% 12.9% Hip Fracture, Hip Arthroplasty, Knee Arthroplasty, and VTE Risk (Upper Limits) in Patients without Anticoagulative Prophylaxis

16 Patients Not Receiving Anticoagulation Prophylaxis: Summary Orthopedic surgery creates the ideal conditions for the development of DVT Orthopedic surgery creates the ideal conditions for the development of DVT Vascular damage Vascular damage Venous stasis Venous stasis Hypercoagulability Hypercoagulability ≥50% of patients undergoing orthopedic surgery will develop DVT ≥50% of patients undergoing orthopedic surgery will develop DVT Most frequently utilized agents all demonstrate superiority compared with placebo Most frequently utilized agents all demonstrate superiority compared with placebo

17 Current Strategies for DVT Prophylaxis Mechanical prophylaxis Mechanical prophylaxis Pharmacologic anticoagulant therapy Pharmacologic anticoagulant therapy Combination therapy Combination therapy Regional anesthesia Regional anesthesia

18 Current Strategies: Mechanical Prophylaxis Intermittent pneumatic compression (IPC) Intermittent pneumatic compression (IPC) Pneumatic plantar compression (foot pump) Pneumatic plantar compression (foot pump) 1. Literature supports use – Sarmiento JBJS Ineffective when BMI > 25 kg/m 2

19 Current Strategies: Mechanical Prophylaxis (cont’d) Advantages Advantages Local antistasis effects Local antistasis effects Systemic humeral effects Systemic humeral effects No increase in bleeding risk No increase in bleeding risk Disadvantages Disadvantages Patient intolerance Patient intolerance Compliance difficulties Compliance difficulties Impractical post-hospital discharge application Impractical post-hospital discharge application Less effective when BMI >25 Less effective when BMI >25

20 Current Strategies: Anticoagulant Therapy and Indications Oral agents Oral agents Warfarin (dose-adjusted to INR 2.0–3.0) Warfarin (dose-adjusted to INR 2.0–3.0) Prophylaxis of venous thrombosis and its extension, and pulmonary embolism Prophylaxis of venous thrombosis and its extension, and pulmonary embolism Aspirin Aspirin May be effective when combined with mechanical agents – Sarmiento JBJS 1999 May be effective when combined with mechanical agents – Sarmiento JBJS 1999

21 Current Strategies: Anticoagulant Therapy and Indications Injectable/parenteral Injectable/parenteral Dose-adjusted unfractionated heparin (UFH) Dose-adjusted unfractionated heparin (UFH) Prophylaxis of venous thrombosis and its extension Prophylaxis of venous thrombosis and its extension Low-molecular-weight heparins (LMWH) Low-molecular-weight heparins (LMWH) Dalteparin: total hip replacement Dalteparin: total hip replacement Enoxaparin: total hip replacement, total knee replacement Enoxaparin: total hip replacement, total knee replacement

22 Current Strategies: Oral Anticoagulant Therapy Warfarin Warfarin Reduces DVT and symptomatic PE rate Reduces DVT and symptomatic PE rate Lieberman, et al. JBJS 1997 Lieberman, et al. JBJS 1997 In combination with mechanical agents, has a reduction in total DVT rate In combination with mechanical agents, has a reduction in total DVT rate Freedman, et al. JBJS 2000 Freedman, et al. JBJS 2000

23 Current Strategies: Oral Anticoagulant Therapy LMWHs LMWHs 1. Fractionated Heparin 1/3 molecular weight of standard Heparin – inhibits Clotting Factor Binds less to plasma protein, increases bioavailability of the LMWHs

24 Current Strategies: Oral Anticoagulant Therapy LMWHs LMWHs Enoxaparin Enoxaparin 1. Dosage - 30mg SC twice daily 2. Treatment begun within 24hrs after THA 3. Significant lowering DVT/PE rate comparable to Warfarin Colwell, et al. JBJS 1994 Colwell, et al. JBJS 1994

25 Current Strategies: Oral Anticoagulant Therapy LMWHs LMWHs Enoxaparin Enoxaparin 1. In TKA may be superior to Warfarin in reducing DVT rate. Heit, et al. Thromb Haemost Heit, et al. Thromb Haemost. 1997

26 Current Strategies: Oral Anticoagulant Therapy LMWHs LMWHs Dalteparin Dalteparin 1. Dosage – 2500 IU SC 4hrs post surgery followed by 5000 IU SC daily 2. Dalteparin proved effective in the reduction of total DVT and symptomatic PE when compared to Heparin Hull, et al. Arch Intern Med Hull, et al. Arch Intern Med. 2000

27 ANTI-COAGULANT THERAPY LMWH’s Organon-Highly selective inhibitor for factor X Organon-Highly selective inhibitor for factor X FDA approved for Hip Fracture, THA, TKA FDA approved for Hip Fracture, THA, TKA

28 Disadvantages LMWH LMWH SQ route SQ route Bleeding risks Bleeding risks 1. Must initiate at least 12 hrs post surgery 2. Contraindicated in regional anesthesia - FDA Advantages Rapid onset Rapid onset No monitoring (LMWH) No monitoring (LMWH) Superior efficacy (LMWH) Superior efficacy (LMWH) Hirsh J, Hoak J. Circulation. 1996;93: Current Strategies: Parenteral Anticoagulant Therapy

29 Current Strategies: Anticoagulant Therapy Duration of Prophylactic Treatment Duration of Prophylactic Treatment Clinical trials supports usage of prophylaxis Clinical trials supports usage of prophylaxis 1. Period of hospitalization – 4-15 days 2. Post-hospitalization – (meta-analysis review) days Hull, et al. Ann Intern Med Hull, et al. Ann Intern Med. 2001

30 Current Strategies: Anticoagulant Therapy Indications for Greenfield Filter Placement Indications for Greenfield Filter Placement Recurrent history of pulmonary emboli Recurrent history of pulmonary emboli Unable to use anticoagulant therapy in the presence of a DVT Unable to use anticoagulant therapy in the presence of a DVT Presence of pulmonary emboli despite anticoagulation therapy Presence of pulmonary emboli despite anticoagulation therapy

31 HipKnee Hip Replacement Replacement Fracture StockingsAdjuvant–– Intermittent Adjuvant Yes Adjuvant pneumatic Grade 2C Grade 1B compression Aspirin––– Adjusted-doseYes unfractionated Grade 2A–– heparin Warfarin Yes Yes Yes INR 2-3INR 2-3INR 2-3 Grade 1A Grade 1A Grade 1B LMWH Yes Yes Yes Grade 1A Grade 1A Grade 1B ACCP 2001 Recommendations: Based on 7 to 10 Days’ Treatment Geerts WH, et al. Chest. 2001;119(suppl):157S.

32 SUMMARY Treatment of DVT is required following THA, TKA,and Hip Fracture Treatment of DVT is required following THA, TKA,and Hip Fracture Aspirin has literature support clearly for THA Aspirin has literature support clearly for THA Warfarin and LMWH clearly show effectivenss for THA,TKA,and Hip Fracture Warfarin and LMWH clearly show effectivenss for THA,TKA,and Hip Fracture Post discharge usage should be for up to 35 days post op Post discharge usage should be for up to 35 days post op

33 Summary TJA places patients at risk for VTE TJA places patients at risk for VTE Thromboprophylaxis: the standard of care following TJA due to high rates of VTE without prophylaxis Thromboprophylaxis: the standard of care following TJA due to high rates of VTE without prophylaxis Significant variation in prescribing practices Significant variation in prescribing practices There are no data for efficacy of combined mechanical/pharmacologic treatments There are no data for efficacy of combined mechanical/pharmacologic treatments Novel thromboprophylactic agents potentially may improve risk/benefit ratio Novel thromboprophylactic agents potentially may improve risk/benefit ratio

34 THANK-YOU


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