Patients undergoing total hip and knee arthroplasty are at increased risk
for the development of venous thromboembolic disease, and there is general
agreement that these patients require prophylaxis.
The selection of a prophylactic agent involves a balance between efficacy
and safety and often needs to be individualized for specific patients and
institutions.
Despite extensive research, the ideal agent for prophylaxis against deep
venous thrombosis has not been identified. The results of randomized trials
indicate that low-molecular-weight heparin, warfarin, and fondaparinux are the
most effective prophylactic agents after total hip arthroplasty and that
low-molecular-weight heparin, warfarin, fondaparinux, and pneumatic
compression boots are the most effective agents after total knee
arthroplasty.
The duration of prophylaxis against deep venous thrombosis after total hip
and knee arthroplasty remains controversial. Prophylaxis should be continued
beyond hospital discharge. In the future, the determination of the duration of
prophylaxis will be based on the risk stratification of individual
patients.
The practice of discharging patients from the hospital without prophylaxis,
even when the decision is based on negative results of procedures that screen
for the presence of deep venous thrombosis, is not cost-effective.