title: Preoperative versus postoperative initiation of thromboprophylaxis following major orthopedic surgery: safety and efficacy of postoperative administration supported by recent trials of new oral anticoagulants.
abstract: In European countries, low-molecular-weight heparin is generally initiated preoperatively for thromboprophylaxis in hip or knee replacement surgery. The objective of this review is to compare pre- and postoperative thromboprophylaxis strategies using available evidence, and discuss the challenges and issues that arise. Surgery is the first step in the process of thrombus formation, but thrombosis is not an instant process and the formation and growth of the thrombus can take several days or weeks. Hence, it may be possible to stop this process if thromboprophylaxis is initiated after surgery. Meta-analyses or systematic reviews comparing pre- and postoperative initiation of therapy have found no consistent differences in efficacy and similar safety (bleeding rates) between the two strategies. The recently available oral anticoagulant dabigatran etexilate provides thromboprophylaxis when administered postoperatively and is as safe as preoperative enoxaparin. Further support for the use of postoperative oral thromboprophylaxis in hip or knee replacement surgery has been provided by the phase III clinical trials of rivaroxaban and apixaban versus preoperative enoxaparin. Postoperative thromboprophylaxis offers the opportunity to change management practices in Europe. As postoperative initiation may have a clinical benefit in some settings (e.g. for neuraxial anesthesia) and practical advantages (e.g. allowing same-day admission), it is a worthwhile thromboprophylactic strategy for hip or knee replacement surgery.
authors.affiliation: Orthopaedic Department, Charité, University Medicine Berlin, Free and Humboldt-University of Berlin, Berlin, Germany. carsten.perka@charite.de.
authors.forename: Carsten
authors.initials: C
authors.lastname: Perka
references.citation: Thromb Res. 1991 Aug 1;63(3):385-90
references.pmid: 1659748
references.citation: Arch Intern Med. 2000 Jul 24;160(14):2199-207
references.pmid: 10904464
references.citation: Arch Intern Med. 1999 Jan 25;159(2):137-41
references.pmid: 9927095
references.citation: Lancet. 1996 Jul 27;348(9022):224-8
references.pmid: 8684199
references.citation: Chest. 2003 Dec;124(6 Suppl):379S-385S
references.pmid: 14668421
references.citation: Lancet. 1970 Nov 14;2(7681):1006-7
references.pmid: 4098043
references.citation: J Bone Joint Surg Br. 2006 Mar;88(3):386-91
references.pmid: 16498018
references.citation: N Engl J Med. 2010 Dec 23;363(26):2487-98
references.pmid: 21175312
references.citation: J Thromb Haemost. 2007 Dec;5(12):2360-7
references.pmid: 17908282
references.citation: BMJ. 1991 Dec 7;303(6815):1431-5
references.pmid: 1773147
references.citation: Clin Appl Thromb Hemost. 2010 Aug;16(4):394-405
references.pmid: 20019020
references.citation: Int Angiol. 2006 Jun;25(2):101-61
references.pmid: 16763532
references.citation: Pharmacotherapy. 2000 Jul;20(7):771-5
references.pmid: 10907967
references.citation: Thromb Haemost. 1997 Jan;77(1):26-31
references.pmid: 9031444
references.citation: Isr Med Assoc J. 2002 Nov;4(11):1040-2
references.pmid: 12489502
references.citation: N Engl J Med. 2008 Jun 26;358(26):2765-75
references.pmid: 18579811
references.citation: Arch Intern Med. 1995 Feb 27;155(4):366-72
references.pmid: 7848019
references.citation: Reg Anesth Pain Med. 2010 Jan-Feb;35(1):64-101
references.pmid: 20052816
references.citation: Thromb Haemost. 2008 Mar;99(3):546-51
references.pmid: 18327403
references.citation: N Engl J Med. 2008 Jun 26;358(26):2776-86
references.pmid: 18579812
references.citation: Thromb Res. 2010 Oct;126(4):e323-6
references.pmid: 20451962
references.citation: Blood Coagul Fibrinolysis. 1999 Aug;10 Suppl 2:S63-70
references.pmid: 10493232
references.citation: Blood Coagul Fibrinolysis. 1995 Dec;6(8):709-17
references.pmid: 8825220
references.citation: Lancet. 2008 Jul 5;372(9632):31-9
references.pmid: 18582928
references.citation: Chest. 2003 Dec;124(6 Suppl):349S-356S
references.pmid: 14668417
references.citation: N Engl J Med. 1973 Mar 15;288(11):545-51
references.pmid: 4568221
references.citation: Thromb Res. 2001 Jan 1;101(1):V155-62
references.pmid: 11342095
references.citation: Lancet. 2007 Sep 15;370(9591):949-56
references.pmid: 17869635
references.citation: Semin Thromb Hemost. 1990 Apr;16(2):151-7
references.pmid: 2191427
references.citation: Chest. 2004 Sep;126(3 Suppl):338S-400S
references.pmid: 15383478
references.citation: J Thromb Haemost. 2007 Nov;5(11):2178-85
references.pmid: 17764540
references.citation: Lancet. 2010 Mar 6;375(9717):807-15
references.pmid: 20206776
references.citation: Arch Intern Med. 2002 Jul 8;162(13):1451-6
references.pmid: 12090880
references.citation: Thromb Res. 1998 Mar 15;89(6):281-7
references.pmid: 9669750
references.citation: Circ Cardiovasc Qual Outcomes. 2010 Nov;3(6):652-60
references.pmid: 20923996
references.citation: Br J Surg. 1986 Mar;73(3):204-8
references.pmid: 3512031
references.citation: Arch Intern Med. 1998 Jul 27;158(14):1525-31
references.pmid: 9679793
references.citation: Arch Intern Med. 2001 Sep 10;161(16):1952-60
references.pmid: 11525697
references.citation: Thromb Res. 2002 Feb 1;105(3):225-31
references.pmid: 11927128
references.citation: J Thromb Haemost. 2007 Jul;5(7):1438-43
references.pmid: 17425687
references.citation: Am J Manag Care. 2010 Nov;16(11):857-63
references.pmid: 21348557
references.citation: Thromb Haemost. 2011 Apr;105(4):721-9
references.pmid: 21225098
references.citation: Arteriosclerosis. 1983 Nov-Dec;3(6):529-46
references.pmid: 6418123
references.citation: N Engl J Med. 1986 Oct 9;315(15):925-9
references.pmid: 3531851
references.citation: Chest. 2008 Jun;133(6 Suppl):381S-453S
references.pmid: 18574271
references.citation: Thromb Res. 2010 Oct;126(4):e298-304
references.pmid: 20797774
references.citation: J Thromb Haemost. 2005 Sep;3(9):2006-14
references.pmid: 16102107
references.citation: N Engl J Med. 1996 Sep 5;335(10):696-700
references.pmid: 8703168
references.citation: Acta Orthop Scand. 2000 Feb;71(1):47-50
references.pmid: 10743992
references.citation: Br J Anaesth. 1995 Nov;75(5):622-30
references.pmid: 7577292
references.citation: Clin Appl Thromb Hemost. 2009 Sep-Oct;15 Suppl 1:17S-24S
references.pmid: 19696041