EARLY DISCHARGE AND THROMBOEMBOLIC DISEASE IN TOTAL JOINT REPLACEMENT PATIENTS

Participants: A.A. Freiberg, L.S. Matthews, M.C. Proctor, L. J. Greenfield

Keywords: total joint replacement, thromboembolic disease, deep venous thrombosis, (DVT), DVT prophylaxis, venous ultrasound scans

Introduction

A variety of methods are used for deep venous thrombosis (DVT) prophylaxis in total joint replacement patients including coumadin, low molecular weight heparin, aspirin, and mechanical compression devices. Controversy exists with respect to the most efficacious intervention, the duration of prophylaxis, and the utility of pre-discharge venous ultrasound scans.

Materials and Methods

We performed a prospective study to determine the incidence of DVT in patients treated with either low dose coumadin or aspirin and sequential compression devices. A bilateral venous duplex study was obtained on postoperative day 3 and at the first post-operative clinic visit (day 14) to evaluate both the acute and longer term incidence of DVT.

Results

Twenty of 120 patients (16.7%) studied with ultrasound on postoperative day 3 had asymptomatic DVT while 6 of 80 (7.5%) had new DVT at follow-up for an overall incidence of 23%. Twelve DVT were distal and 14 proximal. There were four patients with bilateral DVT in the SCD/Aspirin group. We did not find a difference in the incidence of DVT associated with the method of prophylaxis or the site of surgery. However, we did find a clinically important difference in the length of stay that was associated with type of prophylaxis. Patients with SCDs/Aspirin had a mean LOS that was 2.7 days longer than those treated with low dose coumadin ( 7.8 vs 5.1). Eleven patients (14.5%) in the SCD/Aspirin group required readmission or prolonged hospitalization (>6 days ) for DVT treatment vs 1 (2.2%) in the coumadin group.

Conclusion

Coumadin is an effective method of prophylaxis in total joint replacement patients and also reduces the LOS required for treatment when DVT does develop. Patients already on coumadin do not require intravenous heparin thus reducing the length of stay. Coumadin prophylaxis eliminates prolonged hospitalization for intravenous heparin in patients with DVT and allows timely discharge with therapeutic anticoagulation. Pre-discharge venous scans enable early treatment of DVT and limit expensive readmissions. The combination of low dose coumadin prophylaxis and pre-discharge duplex scans appear to offer a cost-effective strategy for addressing this common complication after arthroplasty.