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DVTs Eliminated in Total Hip or Knee Replacement Surgery?

Henry I. Bussey, Pharm.D.
October 2004

Review: Silbersack Y, Taute B-M, Hein W, Podhaisky H. Prevention of deep-vein thrombosis after total hip and knee replacement. The Journal of Bone and Joint Surgery (British) 2004 (August); 86-B(6): 809-812

To date, venographic studies of DVT prophylaxis indicate that our best options for preventing DVT in hip or knee surgery result in about 15% to 25% of patients leaving the hospital with an unrecognized DVT. The results of this small German study suggest that combining enoxaparin with intermittent compression devices may eliminate DVTs in patients undergoing their first unilateral knee or hip replacement.

Patients undergoing a unilateral total replacement of the hip (THR, 61 patients) or knee (TKR, 70 patients) were randomized to receive enoxaparin (40mg daily begun pre-op) combined with either intermittent pneumatic compression (IPC) calf devices (worn for up to 10 days post-op) or graduated compression stocking (worn for up to 3 months post-op). These devices were worn on both legs. Duplex ultrasound at 6 to 12 days post-op detected no DVTs in those wearing the IPC devices and 29% of those wearing the compression stockings (40% in TKR and 14% THR). This difference was highly statistically significant at p < 0.0001. No pulmonary emboli were reported during the 6 to 12 weeks of follow-up.

Although these results are quite impressive, there are a number of considerations:

1. The 40mg pre-op and once a day dosing of enoxaparin usually is not used in the U.S. where 30 mg twice-daily starting post-op is the preferred regimen. Whether outcomes might be different with the twice a day enoxaparin regimen and/or with the first post-op dose being administered as a partial dose at 6 to 8 hours post-op (as advocated by some authorities) remains an unanswered question.
2. What the outcomes would be if fondaparinux, ximelagatran, another low molecular weight heparin, or other antithrombotic agents were used in place of enoxaparin cannot be determined at this time.
3. Duplex ultrasound is not as reliable a screening test for asymptomatic DVT as is venography; but it is less invasive and better tolerated by patients.
4. It should be noted that devices were applied to both legs. In previous studies as many as 25% of the DVTs that occurred were found in the leg that was not operated on.
5. What effect these therapies have on later-occurring DVT and/or PE cannot be determined from these data.
6. It is rather surprising that no DVTs were seen in the TKR patients who received enoxaparin plus IPC devices because previous studies have shown that DVT actually develops during the TKR surgery and, therefore, were considered to not be totally preventable by measures that are started after the surgery.

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