Goals
- Reduce the incidence of pulmonary embolism.
- Reduce the incidence of symptomatic DVT.
- Limit the side effects of chemoprophylaxis (wound drainage, infection risk, bleeding).
Risk Stratification
| Bleeding risk | Standard risk | Elevated VTE risk |
|---|---|---|
| Bleeding disorder Past complication on aspirin, Lovenox, warfarin, or a DOAC History of hemorrhagic stroke Chemoprophylaxis otherwise contraindicated |
No history of VTE No history of a bleeding disorder Concurrent HRT use Inactive malignancy, not on chemotherapy/cancer treatment |
Prolonged immobility Prior VTE (any type or timing) Active malignancy or chemotherapy Hypercoagulable state (Factor V Leiden, Protein C/S deficiency) BMI > 40 |
Proposed Protocol
All groups: intermittent pneumatic compression (SCDs) in hospital; TED stockings are not required; mobilize POD 0 and at least 3× daily thereafter; VTE-prophylaxis education pre-op, in hospital, and at discharge.
For patients NOT on an anticoagulant/antiplatelet before surgery:
| Bleeding risk | Standard risk | Elevated VTE risk |
|---|---|---|
| Mechanical only — portable SCDs ordered pre-op and available at discharge No chemoprophylaxis |
Aspirin 81 mg BID 2 weeks (TKA) / 4 weeks (THA) Start POD 0 in the evening Add a PPI if on aspirin + any NSAID |
Rivaroxaban (Xarelto) 10 mg daily, start POD 1 AM TKA: × 14 days (2 weeks) THA: × 14 days, then aspirin 81 mg BID × 14 days (4 weeks total) |
Aspirin allergy (otherwise standard-risk): use the elevated-risk agent (rivaroxaban) as the alternative.
For patients already on an anticoagulant/antiplatelet: warfarin, a DOAC, or aspirin may serve as postoperative VTE prophylaxis if the patient was on it before surgery. Plavix alone should not serve as VTE prophylaxis.
| Agent | Stop | Restart | Bridging |
|---|---|---|---|
| Warfarin ^ | 5 days prior (goal INR < 1.25) | POD 0 evening | Prefer none unless directed by PCP/cardiology |
| DOAC ^ | 3 days prior | POD 1 AM | Prefer none unless directed |
| Plavix ^ # | 5 days prior | POD 1 AM | Prefer none unless directed |
| Aspirin | OK to continue | Minimum dose 81 mg BID | — |
^ A cardiologist or primary care provider must approve any temporary hold of these agents. # Start aspirin 81 mg BID on POD 0 as VTE prophylaxis after surgery.
Tranexamic Acid (TXA)
- TXA decreases bleeding and is not a pro-thrombotic agent.
- Give a single 1 g preoperative dose before incision to most patients — except those with CrCl < 30, TXA allergy, or active/recent VTE (within 3 months).
Duplex Ultrasonography (DUS)
- Per AAOS guidance, recommend against routine preoperative DUS.
- In patients with known chronic VTE or preoperative unilateral leg swelling, preop DUS may help establish a baseline.
- Unilateral swelling, bruising, and calf/thigh tenderness are common and normal after TKA/THA and are not reliable predictors of VTE — do not use them as indications for DUS.
- Do not order DUS after hip/knee arthroplasty unless there is high clinical suspicion by an experienced provider; ideally the attending surgeon, that surgeon's PA, or the on-call surgeon approves it.
Documentation
Surgeons must clearly state the DVT-prophylaxis plan in the last paragraph of the operative report so it is accessible to anyone caring for the patient postoperatively.