An updated clinical practice guideline just released by the American Academy of Orthopaedic Surgeons (AAOS) Board of Directors recommends how to reduce the likelihood of blood clots after hip or knee replacement surgery, procedures that more than 800,000 Americans undergo each year. The new guideline suggests use of preventive treatments and advises against routinely screening patients after surgery using ultrasound imaging.
"Hip and knee arthroplasty [joint replacement surgery] is among the most successful of procedures in terms of restoring function and minimizing pain. However, one possible complication that orthopaedic surgeons are concerned about is venous thromboembolic disease," said Joshua Jacobs, MD, Academy second vice president, an orthopaedic surgeon at Rush University Medical Center in Chicago, who was chairman of the workgroup that developed the guideline.
Thromboembolic disease encompasses two conditions: deep vein thrombosis (DVT), or formation of a blood clot in a deep vein such as in the thigh or calf, and pulmonary embolism (PE). In the relatively uncommon event of a PE, pieces of a clot break free and travel through the vein to the lung, where they can lodge in an artery. PE typically causes no symptoms, however possible symptoms include shortness of breath, chest pain, light headedness or chest congestion. In very rare cases, PE can be fatal. Likewise, in many patients, DVT causes no symptoms. However, in some patients, DVT can lead to symptoms such as leg swelling and pain that can necessitate further treatment or rehospitalization. The goal of the orthopaedic surgeon is to prevent, as much as possible, the occurrence of PE and DVT following total hip and knee replacement.
According to the guideline, in the absence of prophylaxis, DVT occurs in about 37 percent of patients, as detected by imaging. The majority of those patients will remain asymptomatic and will require no further treatment. Recent studies in Denmark show that only 0.7 percent of hip replacement patients and 0.9 percent of knee replacement patients require hospitalization because of DVT in the first three months after surgery.
"After looking at all available scientific research evidence, in a rigorous fashion to minimize bias, we made recommendations that can help guide practitioners in the safest and most effective ways to prevent this potentially serious complication," said Jacobs.
Among the preventive measures the experts analyzed for safety and effectiveness are mechanical compression devices, designed to improve blood flow in the legs after surgery, as well as drug therapy. Drug therapy involves anticoagulants, commonly called blood thinners, as well as aspirin, which interferes with blood clotting by acting on platelets.
The work group also outlined suggestions for future research to fill in the evidence gaps that were apparent through an exhaustive and systematic review of the medical literature. Further research is deemed critical to develop the optimum strategies to prevent venous thromboembolic disease in the safest and most effective manner.
From the evidence reviewed, the workgroup made the following recommendations for physicians treating patients before hip or knee replacement:
The workgroup also made these recommendations for care after hip or knee replacement:
The full guideline is entitled, "Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty."
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