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A Multi-institutional Cohort Study of Patients Who Underwent Hip or Knee Arthroplasty

Jacques R. Leclerc, MD; Michael Gent, DSc; Jack Hirsh, MD; William H. Geerts, MD; Jeffrey S. Ginsberg, MD; for the Canadian Collaborative Group

Arch Intern Med. 1998;158:873-878.

Background  Despite low molecular weight heparin prophylaxis, the incidence of venographically detected, residual deep vein thrombosis after hip and knee arthroplasty remains high, at approximately 15% and 30%, respectively. Most of these thrombi are asymptomatic and of unknown clinical significance. Nevertheless, because they have the potential to grow, limiting prophylaxis to the in-hospital period may provide inadequate protection.

Methods  We studied a cohort of 1984 consecutive patients who had hip or knee arthroplasty at 1 of 28 participating hospitals. Patients received enoxaparin prophylaxis, 30 mg subcutaneously every 12 hours for up to 14 days, and underwent predischarge compression ultrasonography. Study end points were symptomatic deep vein thrombosis or pulmonary embolism during and after prophylaxis, asymptomatic venous thrombosis detected by predischarge compression ultrasonography, and major hemorrhage. The duration of follow-up was 84 days.

Results  Enoxaparin treatment was started a mean (± SD) of 17.9 ± 10.4 hours after the completion of surgery and was given for a mean of 18.0 ± 6.9 doses. Eighty-two patients (4.1%; 95% confidence interval, 3.3%-5.0%) developed venous thromboembolism. The rates of thromboembolic events during and after prophylaxis were 2.1% and 2.0%, respectively. Only 3 patients (0.15%) had abnormal predischarge compression ultrasonography. Three patients (0.15%) died of pulmonary embolism. Major hemorrhage occurred in 58 patients (2.9%; 95% confidence interval, 2.2%-3.7%).

Conclusions  Postoperative prophylaxis with enoxaparin for a mean of 9 days is associated with a clinically acceptable rate of symptomatic venous thromboembolism and major hemorrhage. Predischarge compression ultrasonography cannot be justified.

From The Montreal General Hospital, McGill University, Montreal, Quebec (Dr Leclerc); the Hamilton Civic Hospitals Research Centre, McMaster University, Hamilton, Ontario (Drs Gent, Hirsh, and Ginsberg); and the Sunnybrook Health Science Centre, Toronto, Ontario (Dr Geerts). Dr Leclerc is now with Cardiovascular Research, Lilly Research Laboratories, Indianapolis, Ind.

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