Preoperative versus postoperative initiation of thromboprophylaxis following major orthopedic surgery: safety and effica
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REVIEW
Open Access
Preoperative versus postoperative initiation of thromboprophylaxis following major orthopedic surgery: safety and efficacy of postoperative administration supported by recent trials of new oral anticoagulants Carsten Perka
Abstract In European countries, low-molecular-weight heparin is generally initiated preoperatively for thromboprophylaxis in hip or knee replacement surgery. The objective of this review is to compare pre- and postoperative thromboprophylaxis strategies using available evidence, and discuss the challenges and issues that arise. Surgery is the first step in the process of thrombus formation, but thrombosis is not an instant process and the formation and growth of the thrombus can take several days or weeks. Hence, it may be possible to stop this process if thromboprophylaxis is initiated after surgery. Meta-analyses or systematic reviews comparing pre- and postoperative initiation of therapy have found no consistent differences in efficacy and similar safety (bleeding rates) between the two strategies. The recently available oral anticoagulant dabigatran etexilate provides thromboprophylaxis when administered postoperatively and is as safe as preoperative enoxaparin. Further support for the use of postoperative oral thromboprophylaxis in hip or knee replacement surgery has been provided by the phase III clinical trials of rivaroxaban and apixaban versus preoperative enoxaparin. Postoperative thromboprophylaxis offers the opportunity to change management practices in Europe. As postoperative initiation may have a clinical benefit in some settings (e.g. for neuraxial anesthesia) and practical advantages (e.g. allowing same-day admission), it is a worthwhile thromboprophylactic strategy for hip or knee replacement surgery. Keywords: Thromboprophylaxis, Hip replacement surgery, Knee replacement surgery, Anticoagulation, Dabigatran etexilate, Rivaroxaban, Apixaban
Introduction Venous thromboembolism (VTE) is a serious complication of elective hip and knee replacement surgery. Without thromboprophylaxis, VTE occurs in approximately 4060% of cases. Hence, evidence-based guidelines recommend thromboprophylaxis for all patients undergoing hip or knee replacement surgery [1,2]. In many European countries, low-molecular-weight heparin (LMWH) is considered the standard therapy for prophylaxis following hip or knee replacement surgery and is initiated preoperatively to maximize efficacy [3]. Correspondence: [email protected] Orthopaedic Department, Charité, University Medicine Berlin, Free and Humboldt-University of Berlin, Berlin, Germany
Preoperative thromboprophylaxis is initiated on the assumption that the surgery itself and the accompanying immobility are the main causes of thrombosis [4-7]. However, as most thrombi develop postoperatively, starting anticoagulant therapy following surgery could also prevent VTE [8-10]. Initiation of thromboprophylaxis after surgery has several potential advantages. It simplifies same-day admission for elective procedures and, as therapy is i
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