title: Balancing Thromboprophylaxis and Bleeding in Total Joint Arthroplasty: Impact of Eliminating Enoxaparin and Predonation and Implementing Pneumatic Compression and Tranexamic Acid.
abstract: Venous thromboembolic disease (VTED) after total hip arthroplasty (THA) and total knee arthroplasty (TKA) poses substantial risk. Pharmacologic prophylaxis against VTED can cause bleeding, transfusion, and associated complications. The ActiveCare+SFT is a portable, intermittent pneumatic compression device (IPCD), providing equivalent VTED prophylaxis to pharmacologic agents without associated bleeding. Tranexamic acid (TXA) is an antifibrinolytic that reduces blood loss after THA and TKA. Our objective was to measure blood transfusion and VTED after eliminating enoxaparin, introducing an IPCD, eliminating autologous blood transfusion, and administering TXA during primary TKA and THA.
  
  
  
  Four consecutive cohorts of THA and TKA patients were studied. Group A, the historical control, received enoxaparin VTED prophylaxis. Group B received IPCD VTED prophylaxis. Group C received IPCD VTED prophylaxis along with TXA (1 g intravenous at incision and closure). Groups A, B, and C predonated 1 unit of autologous blood. Group D received IPCD VTED prophylaxis, TXA as above, but did not donate blood preoperatively.
  
  
  
  Seventeen of 50 patients (34%) in Group A, 7 of 47 (14.9%) patients in Group B, 4 of 43 (9.3%) patients in Group C, and 0 of 46 patients in Group D received transfusions. There were no major symptomatic VTED events.
  
  
  
  Using an IPCD and TXA and discontinuing enoxaparin and preoperative autologous blood donation eliminated blood transfusion in primary THA and TKA without any increase in VTED. Using an IPCD instead of enoxaparin, adding TXA, and eliminating preoperative autologous donation each had an incremental dose response effect. This protocol provides effective VTED prophylaxis equivalent to pharmacologic methods and eliminates transfusion risk in the primary THA and TKA population.
authors.affiliation: Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
authors.forename: Zachary T
authors.initials: ZT
authors.lastname: Sharfman
authors.affiliation: Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
authors.forename: Joshua C
authors.initials: JC
authors.lastname: Campbell
authors.affiliation: Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
authors.forename: James M
authors.initials: JM
authors.lastname: Mirocha
authors.affiliation: Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
authors.forename: Andrew I
authors.initials: AI
authors.lastname: Spitzer
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use; D000933:Antifibrinolytic Agents / Q000008:administration & dosage; D019644:Arthroplasty, Replacement, Hip / Q000379:methods*; D019645:Arthroplasty, Replacement, Knee / Q000379:methods*; D001803:Blood Transfusion; D001804:Blood Transfusion, Autologous; D015331:Cohort Studies; D017984:Enoxaparin / Q000008:administration & dosage*; D005260:Female; D006470:Hemorrhage / Q000517:prevention & control; D006801:Humans; D048228:Intermittent Pneumatic Compression Devices; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D013923:Thromboembolism / Q000188:drug therapy / Q000517:prevention & control*; D014148:Tranexamic Acid / Q000008:administration & dosage*; D020246:Venous Thrombosis / Q000188:drug therapy* / Q000453:epidemiology
chemical_list: D000925:Anticoagulants; D000933:Antifibrinolytic Agents; D017984:Enoxaparin; D014148:Tranexamic Acid
keywords: intermittent pneumatic compression device; preoperative autologous blood donation; total joint replacement; tranexamic acid; transfusion risk; venous thromboembolic disease