Guideline Helps Physicians Reduce Blood Clots After Hip and Knee Replacement

Although hip and knee arthroplasty often are successful in restoring function and minimizing pain in patients with osteoarthritis, venous thromboembolic disease-encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE)-is a possible complication that merits physicians’ consideration, according to the American Academy of Orthopaedic Surgeons (AAOS). Physicians may reduce the probability of blood clots occurring after hip or knee replacement surgery with the use of preventive treatments outlined in a recently released clinical practice guideline, Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty.

PE typically causes no symptoms, the AAOS noted, but shortness of breath, chest pain, light-headedness, or chest congestion may occur and, in rare cases, PE may be fatal. DVT causes no symptoms in many patients, but it may lead to leg swelling and pain that can necessitate further treatment or rehospitalization. Therefore, the goal is to prevent, as much as possible, the occurrence of PE and DVT after total hip and knee replacement.

For physicians treating patients before they undergo replacement surgery, the AAOS guideline made the following recommendations:

•  Advise patients to stop taking antiplatelet medications, such as aspirin and clopidogrel, because these drugs increase the risk of blood loss during surgery.

•  Discuss with patients the timing of stopping of any medication.

•  Because a history of DVT or PE is an additional risk factor for thromboembolic disease, emphasize that patients should discuss any such event with their surgeon. Note that the evidence reviewed for the guideline was insufficient to recommend for or against routinely assessing patients for other possible risk factors.

•  Patients may want to have the surgery performed under regional anesthesia, such as epidural or spinal, rather than general anesthesia. The evidence suggests that these regional approaches do not affect the occurrence of DVT or PE, but they limit blood loss.

For patient care after hip or knee replacement surgery, the guideline made the following recommendations:

•  Do not provide routine postoperative screening for thromboembolic disease with duplex ultrasonography. Such screening does not reduce the rate of symptomatic DVT or PE or the rate of fatal PE significantly.

•  After a hip or knee replacement procedure, provide patients with anticoagulant therapy (unless it is contraindicated because of a medical reason, such as a bleeding disorder or active liver disease) or mechanical compression devices or both. Note that there was insufficient evidence to recommend a specific preventive strategy or the duration of these treatments. Discuss the duration and type of preventive treatment with patients.

•  After a procedure, advise patients to walk as soon as they can do so safely. Although the evidence is insufficient to support the notion that “early mobilization” reduces DVT rates, it is low in cost, of minimal risk, and consistent with current practice.

The AAOS work group that developed the guideline also outlined suggestions for future research to fill in evidence gaps that were apparent through an exhaustive and systematic review of the medical literature. The group deemed further research critical to developing optimum strategies to prevent venous thromboembolic disease in the safest and most effective manner.

For more information, visit the AAOS Web site at http://www.aaos.org. Or, contact the organization at American Academy of Orthopedic Surgeons, 6300 North River Road, Rosemont, IL 60018-4262; telephone: (847) 823-7186; fax: (847) 823-8125. For the full guideline, along with all supporting documentation and work group disclosures, go to http://www.aaos.org/guidelines.

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