Prevention of Deep Venous Thrombosis: The Hospital for Special Surgery Approach

Deep vein thrombosis is the most common complication after total knee and total hip arthroplasty. At the Hospital for Special Surgery we have tried to develop a multimodal approach for deep vein thrombosis prophylaxis. For patients undergoing total hip arthroplasty this approach involves multiple intraoperative and postoperative modalities. These include hypotensive epidural anesthesia, intraoperative heparin, and minimization of venous kinking during the surgery as well as postoperative pneumatic compression devices, early weight bearing, and pharmacologic prophylaxis with either aspirin or warfarin. Intraoperative measures are less important in patients undergoing total knee arthroplasty considering that the intraoperative tourniquet limits the benefits of hypotensive anesthesia and intraoperative heparin. We therefore advocate postoperative combination protocols involving pneumatic compression and either aspirin or warfarin. For institutions that do not use multimodal treatment options, low molecular weight heparin, warfarin, or modern oral thrombin inhibitors such as ximelagran (FDA approval pending) are the treatment of choice.