Venous thromboembolism prophylaxis in orthopaedics and traumatology

Česká verzia

Authors: P. Kessler
Authors place of work: Oddělení hematologi e a transfuziologi e Nemocnice Pelhřimov, p. o., přednosta prim. MUDr. Petr Kessler
Published in the journal: Vnitř Lék 2009; 55(3): 204-210
Category: 15th Parizek's Days

Summary

The paper formulates the following recommendations:
1. Patients with total hip or knee replacement should be prescribed higher prophylactic dose of low molecular weight heparin (LMWH) or fondaparinux or rivaroxaban or dabigatran, patients with proximal femur fracture should be prescribed higher prophylactic dose of LMWH or fondaparinux. Pharmacological prophylaxis should in patients with knee replacement be administered for at least 14 days and longer in patients with increased risk of venous thromboembolism (VTE). It is recommended that the prophylaxis lasts 28 to 35 days in patients with hip replacement or with a proximal femur fracture. Changeover to warfarin and its subsequent administration for 6–8 weeks can be used as an alternative where well‑functioning anticoagulant treatment infrastructure is available. Intermittent pneumatic compression with subsequent pharmacological prophylaxis represents an alternative in bleeding patients or in patients with a high risk of bleeding. 2. Pharmacological prophylaxis is not needed in patients after knee arthroscopy without VTE risk factors in whom tourniquet was applied for < 60 min. Administration of LMWH for 5–7 days is suitable in patients after knee arthroscopy with VTE risk factors or in whom tourniquet was applied for > 60 min., administration of LMWH for 3 weeks is recommended in patients after the arthroscopic anterior cruciate ligament surgery. 3. Administration of LMWH for 7–10 days is indicated in patients with lower limb (LL) fractures treated with osteosynthesis. LMWH administration for the period of the fixation is indicated in patients with LL injury requiring plaster cast or other fixation above the knee. Administration of LMWH for the period of the fixation is indicated in patients with LL injury requiring plaster cast fixation below the knee that have increased VTE risk. 4. IPC or leg pump is recommended in patients with severe trauma who are bleeding or have a high risk of extensive bleeding. Administration of LMWH should be started as soon as the risk of extensive bleeding dissipates. Computer tomography (CT) or nuclear magnetic resonance imagining (NMRI) should be performed in patients with spinal injury with incomplete spinal lesion to exclude perispinal haematoma. Should haematoma occur, IPC should be used and CT or NMRI repeated after a few days; it is recommended to commence LMWH administration only when the haematoma had been stabilized. In case of persisting immobility, continuing LMWH or warfarin prophylaxis is recommended.

Key words:
venous thromboembolism – prophylaxis – LMWH – warfarin – orthopaedic surgery – trauma

Zdroje

1. Geerts WH, Pineo GF, Heit JA et al. Prevention of Venous Thromboembolism. Chest 2004; 126: 338S–400S.

2. Schindler OS, Dalziel R. Post‑thrombotic syndrome after total hip or knee arthroplasty: incidence in patients with asymptomatic deep venous thrombosis. J Orthop Surg (Hong Kong) 2005; 13: 113–119.

3. Abelseth G, Buckley RE, Pineo GE et al. Incidence of deep-vein thrombosis in patients with fractures of the lower extremity distal to the hip. J Orthop Trauma 1996; 10: 230–235.

4. Lassen MR, Borris LC, Nakov RL. Use of the low-molecular-weight heparin reviparin to prevent deep-vein thrombosis after leg injury requiring immobilization. N Engl J Med 2002; 347: 726–730.

5. Testroote M, Stigter W, de Visser DC et al. Low molecular weight heparin for prevention of venous thromboembolism in patients with lower-leg immobilization. Cochrane Database Syst Rev 2008; 4: CD006681.

6. Geerts WH, Bergqvist D, Pineo GF et al.Prevention of venous thromboembolism:American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th ed). American College of Chest Physicians. Chest 2008; 133 (6 Suppl): 381S–453S.

7. Demers C, Marcoux S, Ginsberg JS et al. Incidence of venographically proved deep vein thrombosis after knee arthroscopy. Arch Intern Med 1998; 158: 47–50.

8. Delis KT, Hunt N, Strachan RK et al. Incidence, natural history and risk factors of deep vein thrombosis in elective knee arthroscopy. Thromb Haemost 2001; 86: 817–821.

9. Pulmonary Embolism Prevention (PEP) Trial Collaborative Group. Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) Trial. Lancet 2000; 355: 1295–1302.

10. Collins R, Scrimgeour A, Yusuf S et al. Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin: overview of results of randomized trials in general, orthopedic, and urologic surgery. N Engl J Med 1988; 318: 1162–1173.

11. Planes A, Vochelle N, Mazas F et al. Prevention of postoperative venous thrombosis: a randomized trial comparing unfractionated heparin with low molecular weight heparin in patients undergoing total hip replacement. Thromb Haemost 1988; 60: 407–410.

12. Freedman KB, Brookenthal KR, Fitzgerald RH et al. A meta‑analysis of thromboembolic prophylaxis following elective total hip arthroplasty. J Bone Joint Surg Am 2000; 82: 929–938.

13. Kakkar VV, Howes J, Sharma V et al. A comparative, double-blind, randomised trial of a new second generation LMWH (bemiparin) and UFH in the prevention of post‑operative venous thromboembolism. Thromb Haemost 2000; 83: 523–529.

14. Eriksson BI, Ekman S, Lindbratt S et al. Prevention of thromboembolism with use of recombinant hirudin: results of a double-blind, multicenter trial comparing the efficacy of desirudin (Revasc) with that of unfractionated heparin in patients having a total hip replacement. J Bone Joint Surg Am 1997; 79: 326–333.

15. Amstutz HC, Friscia DA, Dorey F et al. Warfarin prophylaxis to prevent mortality from pulmonary embolism after total hip replacement. J Bone Joint Surg Am 1989; 71: 321–326.

16. Lieberman JR, Wollaeger J, Dorey F et al. The efficacy of prophylaxis with low‑dose warfarin for prevention of pulmonary embolism following total hip arthroplasty. J Bone Joint Surg Am 1997; 79: 319–325.

17. Paiement GD, Wessinger SJ, Hughes R et al. Routine use of adjusted low‑dose warfarin to prevent venous thromboembolism after total hip replacement. J Bone Joint Surg Am 1993; 75: 893–898.

18. Colwell CW, Spiro TE, TrowbridgeAA et al. Use of enoxaparin, a low-molecular-weight heparin, and unfractionated heparin for the prevention of deep venous thrombosis after elective hip replacement: a clinical trial comparing efficacy and safety. J Bone Joint Surg Am 1994; 76: 3–14.

19. Koch A, Ziegler S, Breitschwerdt H et al. Low molecular weight heparin and unfractionated heparin in thrombosis prophylaxis: meta‑analysis based on original patient data. Thromb Res 2001; 102: 295–309.

20. Haas S, Breyer HG, Bacher HP et al. Prevention of major venous thromboembolism following total hip or knee replacement: a randomized comparison of low-molecular-weight heparin with unfractionated heparin (ECHOS Trial). Int Angiol 2006; 25: 335–342.

21. Abad JI, Gómez-Outes A, Martínez--González J. A prospective observational study on the effectiveness and safety of bemiparin, first dose administered 6 h after knee or hip replacement surgery. Arch Orthop Trauma Surg 2007; 127: 665–670.

22. RD Heparin Arthroplasty Group: RD heparin compared with warfarin for prevention of venous thromboembolic disease following total hip or knee arthroplasty. J Bone Joint Surg Am 1994; 76: 1174–1185.

23. Hull R, Raskob GE, Pineo G et al. A comparison of subcutaneous low--molecular-weight heparin with warfarin sodium for prophylaxis against deep-vein thrombosis after hip or knee implantation. N Engl J Med 1993; 329: 1370–1376.

24. Francis CW, Pellegrini VD, Totterman S et al. Prevention of deep-vein thrombosis after total hip arthroplasty: comparison of warfarin and dalteparin. J Bone Joint Surg Am 1997; 79: 1365–1372.

25. Lassen MR, Bauer KA, Eriksson BI et al. Postoperative fondaparinux versus preoperative enoxaparin for prevention of venous thromboembolism in elective hip-replacement surgery: a randomised double-blind comparison. Lancet 2002; 359: 1715–1720.

26. Turpie AGG, Bauer KA, Eriksson BI et al. Postoperative fondaparinux versus postoperative enoxaparin for prevention of venous thromboembolism after elective hip-replacement surgery: a randomised double-blind trial. Lancet 2002; 359: 1721–1726.

27. Eriksson BI, Dahl OE, Rosencher N et al. Dabigatran etexilate versus enoxaparin for prevention of venous thromboembolism after total hip replacement: a randomised, double-blind, non‑inferiority trial. Lancet 2007; 370: 949–956.

28. Eriksson BI, Borris LC, Friedman RJ et al. Rivaroxaban versus enoxaparin for thromboprophylaxis after hip arthroplasty. N Engl J Med 2008; 358: 2765–2775.

29. Eriksson BI, Turpie AG, Lassen MR et al. A dose escalation study of YM150, an oral direct factor Xa inhibitor, in the prevention of venous thromboembolism in elective primary hip replacement surgery. J Thromb Haemost 2007; 5: 1660–1665.

30. Lassen MR, Dahl O, Mismetti P et al. SR123781A: a new once-daily synthetic oligosaccharide anticoagulant for thromboprophylaxis after total hip replacement surgery: the DRIVE (Dose Ranging Study in Elective Total Hip Replacement Surgery) study. J Am Coll Cardiol 2008; 51: 1498–1504.

31. White RH, Romano PS, Zhou H et al. Incidence and time course of thromboembolic outcomes following total hip or knee arthroplasty. Arch Intern Med 1998; 158: 1525–1531.

32. Eriksson, BI, Lassen, MR. PENTasaccharide in HIp-FRActure Surgery Plus (PENTHIFRA Plus) Invetigators. Duration of prophylaxis against venous thromboembolism with fondaparinux after hip fracture surgery: a multicenter, randomized, placebo-controlled, double-blind study. Arch Intern Med 2003; 163: 1337–1342.

33. Dahl OE, Andreassen G, Aspelin T et al. Prolonged thromboprophylaxis following hip replacement surgery: results of a double-blind, prospective, randomised, placebo-controlled study with dalteparin (Fragmin). Thromb Haemost 1997; 77: 26–31.

34. Planes A, Vochelle N, Darmon JY et al. Risk of deep-venous thrombosis after hospital discharge in patients having undergone total hip replacement: double-blind randomised comparison of enoxaparin versus placebo. Lancet 1996; 348: 224–228.

35. Comp PC, Spiro TE, Friedman RJ et al. Prolonged enoxaparin therapy to prevent venous thromboembolism after primary hip or knee replacement. J Bone Joint Surg Am 2001; 83: 336–345.

36. Prandoni P, Bruchi O, Sabbion P, et al. Prolonged thromboprophylaxis with oral anticoagulants after total hip arthroplasty: a prospective controlled randomized study. Arch Intern Med 2002; 162; 1966–1971.

37. Westrich GH, Sculco TP. Prophylaxis against deep venous thrombosis after total knee arthroplasty: pneumatic planter compression and aspirin compared with aspirin alone. J Bone Joint Surg Am 1996; 78: 826–834.

38. Haas SB, Insall JN, Scuderi GR et al. Pneumatic sequential-compression boots compared with aspirin prophylaxis of deep-vein thrombosis after total knee arthroplasty. J Bone Joint Surg Am 1990; 72: 27–31.

39. Colwell CW, Spiro TE, Trowbridge AA et al. Efficacy and safety of enoxaparin versus unfractionated heparin for prevention of deep venous thrombosis after elective knee arthroplasty. Clin Orthop 1995; 321: 19–27.

40. Kaempffe FA, Lifeso RM, Meinking C. Intermittent pneumatic compression versus Coumadin: prevention of deep vein thrombosis in low-extremity total joint arthroplasty. Clin Orthop 1991; 269: 89–97.

41. Lieberman JR, Sung R, Dorey F et al. Low‑dose warfarin prophylaxis to prevent symptomatic pulmonary embolism after total knee arthroplasty. J Arthroplasty 1997; 12: 180–184.

42. Robinson KS, Anderson DR, Gross M et al. Ultrasonographic screening before hospital discharge for deep venous thrombosis after arthroplasty: the Post‑Arthroplasty Screening Study; a randomized, controlled trial. Ann Intern Med 1997; 127: 439–445.

43. Ginsberg JS, Turkstra F, Buller HR et al. Postthrombotic syndrome after hip or knee arthroplasty: a cross-sectional study. Arch Intern Med 2000; 160: 669–672.

44. Leclerc JR, Geerts WH, Desjardins L et al. Prevention of venous thromboembolism after knee arthroplasty: a randomized, double-blind trial comparing enoxaparin with warfarin. Ann Intern Med 1996; 124: 619–626.

45. Brookenthal KR, Freedman KB, Lotke PA et al. A meta‑analysis of thromboembolic prophylaxis in total knee arthroplasty. J Arthroplasty 2001; 16: 293–300.

46. Bauer KA, Eriksson BI, Lassen MR et al. Fondaparinux compared with enoxaparin for the prevention of venous thromboembolism after elective major knee surgery. N Engl J Med 2001; 345: 1305–1310.

47. Turpie AGG, Bauer KA, Eriksson BI et al. Fondaparinux vs enoxaparin for the prevention of venous thromboembolism in major orthopedic surgery: a meta‑analysis of 4 randomized double-blind studies. Arch Intern Med 2002; 162: 1833–1840.

48. Eriksson BI, Dahl OE, Rosencher N et al. Oral dabigatran etexilate vs. subcutaneous enoxaparin for the prevention of venous thromboembolism after total knee replacement: the RE-MODEL randomized trial. J Thromb Haemost 2007; 5: 2178–2185.

49. Lassen MR, Ageno W, Borris LC et al. Rivaroxaban versus enoxaparin for thromboprophylaxis after total knee arthroplasty. N Engl J Med 2008; 358: 2776–2786.

50. Lassen MR, Davidson BL, Gallus A et al. The efficacy and safety of apixaban, an oral, direct factor Xa inhibitor, as thromboprophylaxis in patients following total knee replacement. J Thromb Haemost 2007; 5: 2368–2375.

51. Eikelboom JW, Quinlan DJ, Douketis JD. Extended-duration prophylaxis against venous thromboembolism after total hip or knee replacement: a meta‑analysis of the randomised trials. Lancet 2001; 358: 9–15.

52. Fisher CG, Blachut PA, Salvian AJ et al. Effectiveness of leg compression devices for the prevention of thromboembolic disease in orthopaedic trauma patients: a prospective, randomized study of compression alone versus no prophylaxis. J Orthop Trauma 1995; 9: 1–7.

53. Eriksson, BI, Bauer, KA, Lassen, MR et al. Fondaparinux compared with enoxaparin for the prevention of venous thromboembolism after hip-fracture surgery. N Engl J Med 2001; 345: 1298–1304.

54. Powers PJ, Gent M, Jay RM et al. A randomized trial of less intense postoperative warfarin or aspirin therapy in the prevention of venous thromboembolism after surgery for fractured hip. Arch Intern Med 1989; 149: 771–774.

55. Small NC. Complications in arthroscopic surgery performed by experienced arthroscopists. Arthroscopy 1988; 4: 215–221.

56. Schippinger G, Wirnsberger GH, Obernosterer A et al. Thromboembolic complications after arthroscopic knee surgery: incidence and risk factors in 101 patients. Acta Orthop Scand 1998; 69: 144–146.

57. Wirth T, Schneider B, Misselwitz F et al. Prevention of venous thromboembolism after knee arthroscopy with low-molecular weight heparin (reviparin): results of a randomized controlled trial. Arthroscopy 2001; 17: 393–399.

58. Michot M, Conen D, Holtz D et al. Prevention of deep-vein thrombosis in ambulatory arthroscopic knee surgery: a randomized trial of prophylaxis with low-molecular weight heparin. Arthroscopy 2002; 18: 257–263.

59. Camporese G, Bernardi E, Prandoni P et al. Low-molecular-weight heparin versus compression stockings for thromboprophylaxis after knee arthroscopy: a randomized trial. Ann Intern Med 2008; 149: 73–82.

60. Marlovits S, Striessnig G, Schuster R et al. Extended-duration thromboprophylaxis with enoxaparin after arthroscopic surgery of the anterior cruciate ligament: a prospective, randomized, placebo-controlled study. Arthroscopy 2007; 23: 696–702.

61. Kujath P, Spannagel U, Habscheid W. Incidence and prophylaxis of deep venous thrombosis in outpatients with injury of the lower limb. Haemostasis 1993; 23 (Suppl): 20–26.

62. Kock HJ, Schmit-Neuerburg KP, Hanke J et al. Thromboprophylaxis with low-molecular-weight heparin in outpatients with plaster-cast immobilisation of the leg. Lancet 1995; 346: 459–461.

63. Jorgensen PS, Warming T, Hansen K et al. Low molecular weight heparin (Innohep) as thromboprophylaxis in outpatients with a plaster cast: a venografic controlled study. Thromb Res 2002; 105: 477–480.

64. Ettema HB, Kollen BJ, Verheyen CC et al. Prevention of venous thromboembolism in patients with immobilization of the lower extremities: a meta‑analysis of randomized controlled trials. J Thromb Haemost 2008; 6: 1093–1098.

65. Bergqvist D, Lowe G. Venous thromboembolism in patients undergoing laparoscopic and arthroscopic surgery and in leg casts. Arch Intern Med 2002; 162: 2173–2176.

66. Geerts WH, Code KI, Jay RM et al. A prospective study of venous thromboembolism after major trauma. N Engl J Med 1994; 331: 1601–1606.

67. Nathens AB, McMurray MK, Cuschieri J et al. The practice of venous thromboembolism prophylaxis in the major trauma patient. J Trauma 2007; 62: 557–562.

68. Geerts WH, Code KI, Jay RM et al. A prospective study of venous thromboembolism after major trauma. N Engl J Med 1994; 331: 1601–1606.

69. Kurtoglu M, Yanar H, Bilsel Y et al. Venous thromboembolism prophylaxis after head and spinal trauma: intermittent pneumatic compression devices versus low molecular weight heparin. World J Surg 2004; 28: 807–811.

70. Stannard JP, Lopez-Ben RR, Volgas DA et al. Prophylaxis against deep-vein thrombosis following trauma: a prospective, randomized comparison of mechanical and pharmacologic prophylaxis. J Bone Joint Surg Am 2006; 88: 261–266.