Should deep venous thrombosis prophylaxis be used in fast-track hip and knee replacement?

Should deep venous thrombosis prophylaxis be used in fast-track hip and knee replacement? Open Access-This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the source is credited. During the last decade, in-hospital programs for patients undergoing total hip replacement (THA) and total knee replacement (TKA) have changed dramatically from (1) staying in bed for 1–3 days on epidural pain treatment followed by mobilization on crutches for weeks including several restrictions in daily activities, to (2) mobilization a few hours after surgery, with no restrictions in daily activities and no more than 2–4 days in hospital (Kerr and Kohan 2008, Husted et al. 2011, Malviya et al. 2011). This change has been possible due to optimized opioid-sparing multimodal analgesia protocols together with local infiltration analgesia techniques, and a detailed education of the patients before, during, and after the operation. In that same period, evidence-based guidelines from the American College of Chest Physicians recommended pharmacological prophylaxis after THA and TKA for at least 10 days but preferably up to 35 days (Geerts et al. 2008). This recommendation is mainly based on randomized studies comparing current and new low-molecular-weight heparins (LMWH) and other anticoagulatory agents with a primary efficacy outcome on deep-vein thrombosis (DVT) including the non-symptomatic cases found by venography (Eriksson et al. 2008, Kakkar et al. 2008, Turpie et al. 2009, Lassen et al. 2010a, b). These authors did not state when their patients were mobilized after surgery, or for how many hours a day they were mobilized—factors that are known to have major importance in the development of DVT. However, some of the reports described a hospital stay of between 8 and 12 days (Turpie et al 2009, Lassen et al. 2010a, b), suggesting slow mobilization of patients. Furthermore, there have been reports of a possible risk of complications when patients are treated with long-term thromboprophylaxis, complications such as wound oozing, bleeding, or deep infection (Jameson et al. 2010). It is therefore important to treat patients for the shortest period possible to prevent symptomatic DVT and pulmonary embolism, but probably not the asymptomatic and more frequent DVT, although the latter requires further evaluation. Orthopedic surgeons worldwide have questioned whether we must treat our joint replacement patients for such long periods as recommended , and there is an open debate on how to create …