Potyk DK, Tabbarah HJ.
The pathogenesis and prevention of thromboembolic complications in patients
undergoing total hip replacement.
J Gen Intern Med 1993 Apr;8(4):213-9

Southern California Permanente Medical Group, Bellflower 90706.

A 1987 survey of U.S. orthopedic surgeons found that 84% used some form of DVT
prophylaxis. Ten percent used prophylaxis only for their "high-risk patients,"
and 6% never used prophylaxis. Twenty percent of the surgeons had at least one
THR patient die from a fatal PE in the last five years. Fifty percent of the
surgeons using warfarin had subsequently discontinued its use because of bleeding
complications and monitoring difficulties. Compared with a survey done 13 years
previously, this recent study showed a dramatic rise in the number of surgeons
using DVT prophylaxis. The majority, however, were using methods that are
ineffective: 67% used aspirin and 17% used fixed doses of subcutaneous heparin.
Because the incidences of DVT and PE in THR patients are high, all of these
patients should receive prophylaxis. The standard LDH regimen, effective for
patients receiving gynecologic, general, and most orthopedic procedures, is
ineffective for THR patients. The available prophylactic methods proven to reduce
DVT and PE in THR patients are adjusted-dose subcutaneous heparin, dextrans,
low-dose warfarin, and EPC. Comparative studies have not clearly demonstrated
superiority of any one method. However, low-dose warfarin may offer better
protection in very high-risk patients. External pneumatic compression offers
protection without increasing bleeding risks. Dextrans are effective but are
expensive and may be associated with significant side effects. Adjusted-dose
subcutaneous heparin is also effective but is cumbersome to use.
Low-molecular-weight heparin appears to be a promising alternative. We recommend
the routine use of EPC and reserve low-dose warfarin fro patients with histories
of prior thromboembolic or venous disease.(ABSTRACT TRUNCATED AT 250 WORDS)