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Evidence summaries

Extended DVT Prophylaxis after Hospital Discharge in Patients with Elective Hip Arthroplasty

Extended thromboprophylaxis after discharge in patients with elective hip arthroplasty reduces the risk of venous thromboembolism by 60%. Level of evidence: "A"

A systematic review 1 included 6 studies on patients discharged after elective hip arthroplasty. Duration of thromboprophylaxis after discharge ranged from 18 to 29 days. Compared with placebo, extended out-of-hospital prophylaxis decreased the frequency of all episodes of deep venous thrombosis (DVT) (RR 0.41, 95% CI 0.32 to 0.54), proximal venous thrombosis (RR 0.31, 95% CI 0.20 to 0.47), and symptomatic venous thromboembolism (RR 0.36, 95% CI 0.20 to 0.67). In placebo group, rate for any DVT was 22.5%, proximal venous thrombosis 11.2%, and symptomatic venous thromboembolism 4.2%. Major bleeding was rare, occurring in only one patient in the placebo group.

A systematic review2 included 9 studies (n=3 999) comparing extended-duration thromboprophylaxis (8 studies used LMWH and 1 study unfractionated heparin) with placebo or untreated control in patients undergoing elective total hip or knee replacement. Seven studies included only patients undergoing total hipreplacement and 2 included both total hip andknee replacements. All patients received in-hospital thromboprophylaxis. Extended-duration prophylaxis for 30-42 days reduced symptomatic venous thromboembolism (VTE) (1.3% vs 3.3%; OR 0.38, 95% CI 0.24 to 0.61, NNT=50). There was a greater risk reduction in patients undergoing hip replacement (1.4% vs 4.3%, OR 0.33, 95% CI 0.19 to 0.56, NNT=34) compared with knee replacement (1.0% vs 1.4%; OR 0.74, 95% CI 0.26 to 2.15, NNT=250). A significant reduction in symptomless venographic deep vein thrombosis was also observed (9.6% vs 19.6%; OR 0.48, 95% CI 0.36 to 0.63, NNT=10). There was no increase in major bleeding but extended-duration prophylaxis was associated with excess minor bleeding (3.7% vs 2.5%; OR 1.56, 95% CI 1.08 to 2.26, NNH=83).

A systematic review 3 included 8 studies (n=2 917), and compared prolonged (≥21 days) with standard-duration (7 to 10 days) thromboprophylaxis (with fondaparinux, warfarin, enoxaparin, or dalteparin) after major orthopedic surgery (total hip replacement 6 studies, total knee or total hip replacement 1 study, surgery for hip fracture 1 study) in adults. Prolonged prophylaxis resulted in fewer cases of pulmonary embolism (PE) (OR 0.14, 95% CI 0.04 to 0.47; 5 studies) and symptomatic DVT (OR 0.36, 95% CI 0.16 to 0.81; 4 studies). There were fewer symptomatic objectively confirmed episodes of venous thromboembolism (RR 0.38, 95% CI 0.19 to 0.77; 4 studies), nonfatal PE (OR 0.13, 95% CI 0.03 to 0.54; 4 studies), and DVT (RR 0.37, 95% CI 0.21 to 0.64; 7 studies) with prolonged prophylaxis. There was more minor bleeding events with prolonged prophylaxis (OR 2.44, 95% CI 1.41 to 4.20), and 1 study on hip fracture surgery suggested more surgical-site bleeding events (OR 7.55, 95% CI 1.51 to 37.64) with prolonged prophylaxis.

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    References

    • Hull RD, Pineo GF, Stein PD, Mah AF, MacIsaac SM, Dahl OE, Butcher M, Brant RF, Ghali WA, Bergqvist D, Raskob GE. Extended out-of-hospital low-molecular-weight heparin prophylaxis against deep venous thrombosis in patients after elective hip arthroplasty: a systematic review. Ann Intern Med 2001 Nov 20;135(10):858-69. [PubMed]
    • Eikelboom JW, Quinlan DJ, Douketis JD. Extended-duration prophylaxis against venous thromboembolism after total hip or knee replacement: a meta-analysis of the randomised trials. Lancet 2001;358(9275):9-15. [PubMed]
    • Sobieraj DM, Lee S, Coleman CI et al. Prolonged versus standard-duration venous thromboprophylaxis in major orthopedic surgery: a systematic review. Ann Intern Med 2012;156(10):720-7. [PubMed][DARE]

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