![]() Where opinions diverge is how best to reconcile and balance the dual priorities of preventing VTED while minimizing bleeding complications. There is undisputed agreement that the catastrophic complication of a fatal PE must be prevented. 20, 26, 27, 32, 50Ĭlearly, the controversy between these two sets of guidelines and their proponents has underscored the critical concern about bleeding and its associated complications. In contrast, risk stratification is recommended, and for those patients at low risk for VTED, alternative prophylactic regimens are offered that significantly reduce the risk of bleeding complications. The AAOS guidelines reject the underlying assumptions of the ACCP guidelines and therefore aggressive recommendations for chemoprophylaxis and anticoagulation. The goal of these guidelines therefore is to prevent symptomatic PE, and not DVT. ![]() In contrast, guidelines published by the American Academy of Orthopaedic Surgeons (AAOS) dispute the causal relationship between DVT and PE, and note that no scientific evidence suggests that any prophylactic regimen, in particular any of those recommended by the ACCP, has actually reduced the incidence of PE after TKA. Bleeding as a result of this anticoagulation, although rare, may create serious complications at the surgical site, such as wound drainage, hematoma, need for return to the operating room, and infection, which, in turn, may delay rehabilitation or impair the overall outcome of knee replacement. These guidelines call for aggressive pharmacologic anticoagulation to prevent DVT formation and propagation. This is based on an understanding that DVTs will propagate and embolize in a certain percentage of patients, and that reducing the occurrence of DVT should in turn reduce the most feared of outcomes-symptomatic and fatal PE. Those published by the American College of Chest Physicians (ACCP) 17 acknowledge reduction in the rate of venographically proven DVT as an acceptable surrogate for reducing global VTED and all of its sequelae, including asymptomatic and symptomatic DVT and PE, fatal PE, chronic pulmonary hypertension, recurrent DVT, and postphlebitic syndrome. From medical, economic, and social perspectives, VTED is one of the great challenges facing the knee replacement surgeon.Įvidence-based guidelines are available to help guide the orthopedic surgeon in choosing an effective VTED prophylaxis regimen. ![]() Furthermore, with increased scrutiny by regulatory agencies, VTED and its prophylaxis have become measures of quality of care and determinants of reimbursement by payers. 15 Because it is impossible to predict which patients will develop VTED, screening protocols are unreliable, and because treatment of established VTE does not reliably prevent secondary complications, prophylaxis of VTED after total knee arthroplasty (TKA) is mandatory to minimize the sometimes catastrophic sequelae of this disease. ![]() 17 It is estimated that roughly 90% of these symptomatic pulmonary emboli originate from lower extremity DVT. Symptomatic pulmonary embolus (PE) may occur in as many as 10% of patients and may be fatal in up to 1.7%. The incidence of total deep vein thrombosis (DVT) without prophylaxis is between 40% and 85%, and it is between 5% and 22% for proximal DVT. Venous thromboembolic disease (VTED) continues to be a major threat to patients undergoing total knee arthroplasty. “The prevention of thrombophlebitis and pulmonary embolism should be a major goal of every orthopedic surgeon who performs total knee arthroplasty.”
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