Impact of venous thromboembolism on clinical management and therapy after hip and knee arthroplasty

Postoperative deep vein thrombosis (DVT) occurs most often in the large veins of the legs in patients undergoing major joint arthroplasty and major surgical procedures. These patients remain at high risk for venous thromboembolic events. In patients undergoing total hip or total knee arthroplasty (THA or TKA, respectively), different patterns of altered venous hemodynamics and hypercoagulability have been found, thus the rate of distal DVT is higher than that of proximal DVT after TKA. In addition, symptomatic venous thromboembolism (VTE) occurs earlier after TKA than THA; however, most of those events occur after hospital discharge. Consequently, extended thromboprophylaxis after discharge should be considered and is particularly important after THA owing to the prolonged risk period for VTE. Evidence-based guideline recommendations for the prevention of VTE in these patients have not been fully implemented. This is partly owing to the limitations of traditional anti coagulants, such as the parenteral route of administration or frequent coagulation monitoring and dose adjustment, as well as concerns about bleeding risks. The introduction of new oral agents (e.g., dabigatran etexilate and rivaroxaban) may facilitate guideline adherence, particularly in the outpatient setting, owing to their oral administration without the need for routine coagulation monitoring. Furthermore, the direct Factor Xa inhibitor rivaroxaban has been shown to be more effective than enoxaparin in preventing VTE.