Prevention of Venous Thromboembolism in Total Knee and Hip Replacement

Case presentation: A 69-year-old woman had a cemented hip replacement 15 years previously, which initially fared well but then gradually failed because of aseptic loosening. She developed pain in her hip and was scheduled for a revision total hip replacement. A formal venous thromboembolism (VTE) risk assessment was undertaken before surgery according to the Hospital's policy for all orthopedic admissions. The risk assessment identified 2 conflicting issues. First, the patient had a particularly high risk of VTE, having had an above-knee deep vein thrombosis after her primary hip replacement and now required a major surgery, namely a revision hip arthroplasty. Second, she had a greater than usual risk of bleeding after surgery because of her obesity and the need for a large soft-tissue exposure, long-term aspirin, and supplementary bone graft from her iliac crest. The surgeon was faced with a common orthopedic problem, providing effective VTE prophylaxis without causing an equally important problem of surgical bleeding.Hip and knee replacement operations are now commonly performed, around 1 million annually in the United States and about the same number in Europe. These procedures are among the most successful and life-changing interventions available.However, the release of thromboplastins from dissected soft tissue and especially reamed bone, as well as venous stasis both during surgery and during relative postoperative immobility, provoke a high rate of thromboembolism.Several measures reduce the risk of VTE, but orthopedic surgeons are intuitively and properly concerned about the potential hemorrhagic side effect of pharmacological prophylaxis, which is associated with prolonged recovery, wound failure, and even periprosthetic infection.1 After all, following the Hippocratic principle of primum non nocere, the most thrombosceptic surgeons have even argued that whereas a thombosis is an act of God, bleeding is caused by a surgeon. Who is to say that a symptomatic leg …