Total Hip: Anticoagulation Policy

Total joint replacement surgery involves risk. One of the more common risks is Deep Venous Thromboembolism or DVT. This is not as serious as the risk of Pulmonary Embolism or PE. Every patient has their own unique set of risk factors for these problems. The risk of DVT is somewhere around 4-14% after Total Hip and Total Knee surgery, with treatment. Without treatment it would be around 40%. The risk of Pulmonary Embolism after the same surgery is 1-2%. The risk of this being fatal, or killing the patient, is around 0.1%

It is important to realize that there is not a direct correlation between a blood clot in the legs (DVT) and a Pulmonary Embolism (PE). It is not at all uncommon for a patient to develop a PE and not have any clots in their legs. If there was a direct correlation, almost every patient with a clot in their legs would develop a PE and every PE patient would have a clot in their legs. This is not the case. Case in point: DVT are 2 to 3 times more common after total knee arthroplasty than after total hip arthroplasty, but total knee arthroplasty patients have an equal or reduced incidence of PE, not a two to threefold increase.

There is quite a bit of controversy over how to manage patients after Hip and Knee Replacement surgery. The surgeons are certainly worried about the potential for clots, but realize there is more to the story. The other part of the story is the fact that more aggressive anticoagulation is associated with an increased risk of complications for the patient. The increased risks are 1) increased risk of infection, 2) increased risk of wound healing problems-which lead directly to infection, 3) increased risk of hematoma- which will lead to increased risk of infection if that patient has to be taken back to the operating room to drain the hematoma, and with hematoma, comes increased risk of stiffness, and an unhappy patient. The level of your blood thinning can be monitored by a test called an INR, when Coumadin (generic name warfarin) is used. Our goal for your INR is less than or equal to 2.0. The internists want that level between 2.0 and 3.0. With all due respect, they do not understand the increased risk associated with that degree of blood thinning. One study showed that the two biggest risk factors for developing and infection after surgery were 1) the use of a drain, and 2) a high INR (greater than 2.0). Another study showed that by following what are called the Chest Guidelines, one institution's rate of complications related to immediate post-procedure hematoma/seroma/hemorrhage went from 1.4% to 8.7%. This increase is statistically significant and unacceptable. You can see that by doing this, we have made the treatment worse than the disease.

There are multiple ways to protect patients after Total Joint Replacement surgery. This includes pumps on the feet and legs during and after surgery, Coumadin, low molecular weight heparin compounds, and aspirin. Early ambulation after surgery is very effective, and 95% of our patients walk the day of surgery. Walking the day of surgery is associated with an 80% reduction in the rate of DVT. In a recent review of 4253 patients, published in the Journal of Bone and Joint Surgery, British Volume, 91-B, ,pages 645-648, Aspirin was shown to have the best protection against fatal pulmonary embolism for the patients following this type of surgery.

Please realize that our institution will treat each patient as an individual case, respecting each patient unique situation. We feel that this individualized approach is best, and our doctors will pick a regimen that is best suited to your situation, considering all factors.