Venous Thromboembolism Is Rare with a Multimodal Prophylaxis Protocol after Total Hip Arthroplasty

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Abstract
We evaluated the safety and efficacy of a multimodal approach for prophylaxis of thromboembolism after total hip arthroplasty, which includes preoperative discontinuation of procoagulant medication; autologous blood donation; hypotensive epidural anesthesia; intravenous administration of heparin during surgery and before femoral preparation; aspiration of intramedullary contents; pneumatic compression; knee-high elastic stockings; and early mobilization and chemoprophylaxis for 4 to 6 weeks (aspirin 83%; warfarin 17%). One thousand nine hundred forty-seven consecutive, nonselected patients (2032 total hip arthroplasties) who received this multimodal prophylaxis were observed prospectively for 3 months. The incidence of asymptomatic deep vein thrombosis assessed by ultrasound in the first 171 patients was 6.4%. The incidence of clinical deep vein thrombosis in the subsequent 1776 patients was 2.5%. Symptomatic pulmonary embolism occurred in 0.6% (12 of 1947; nine in patients receiving aspirin and three in patients receiving Coumadin), none of them fatal. One patient died of a myocardial infarct. This multimodal approach is safe and efficacious and compares favorably with those reported in the literature and with our historic controls. If these preventive measures are strictly observed during the perioperative period, postoperative chemoprophylaxis does not need to be aggressive in the patient without predisposing factors. Our low rate of deep vein thrombosis and pulmonary embolism do not support routine anticoagulation prophylaxis with drugs that increase risk of bleeding. Level of Evidence: Therapeutic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.