Complications After Joint Replacement Surgery
What are the risk factors for developing blood clots after joint replacement surgery?
There are numerous risk factors because of which patients are at increased risk of developing blood clots in their calf muscles. Patients who have a history of malignancy, especially if they’re on chemotherapy, patients who have antiphospholipid syndrome, patients with past history of blood clots, patients who are on oral contraceptive pills and on other medications like tamoxifen, raloxifene, are at increased of developing blood clots.
In addition, patients who have high BMI, body mass index, who have history of strokes and atherosclerosis are at increased risk for developing blood clots after joint replacement surgery. In addition, there is a genetic predisposition. Patients with heritable thrombophilia, antithrombin III, protein C deficiency, and prothrombin gene mutation and similar genetic predispositions are at increased risk of developing blood clots after surgery.
Should routine screening be done after joint replacement surgery to detect blood clots?
The American Academy of Orthopedic Surgeons has only one strong recommendation and that is not to do routine postoperative ultrasonography and screen for patients for blood clots after hip and knee replacement surgery. The reason for that is that many times small clots are formed which are insignificant and the patients get treated with very potent anticoagulants which increases their risk of bleeding into the joint and bleeding elsewhere.
What are the complications of using very high-potent anticoagulant therapy for preventing blood clots after artificial joint replacement surgery?
The problem with potent anticoagulant drugs is that they can cause significant complications including death in the postoperative period. They have to be used very carefully in very targeted indications. As example, use of heparin may cause anticoagulant-induced persistent wound drainage. It can cause increased risk of infection after the joint.
What is your preferred method for preventing blood clots after joint replacement surgery?
I follow a multimodal method for preventing blood clots. Pharmacological treatment is a small part of it. It is very important to decrease the hypercoagulable state, to decrease the stasis and decrease the endothelial injury after joint replacement surgery. Preoperatively, I assess the risk for thrombosis and discontinue procoagulant medications like vitamin K, tamoxifen, oral contraceptives, and that decreases the hypercoagulable state. Preoperative autogenous blood donation has shown to decrease the risk of stasis; however, the blood that is donated preoperatively has to be thrown away and is not covered by insurance.
Additionally, the results have not shown to be very significant and that is something which we do not currently strongly advocate. I therefore do not do preoperative blood donation to lower the hematocrit and decrease the risk of blood clots in every patient undergoing joint replacement surgery.
Surgically, if a cemented prosthesis is used, preheating the prosthesis reduces the curing time and decreases the surgical time and therefore decreases the risk of blood clots. Postoperatively, ankle pumps, which means moving the ankle up and down, keeps the blood moving and improves the femoral vein flow and decreases the risk of blood clots. I recommend continuing these ankle pumps till there is no swelling.
I always ask patients to use elastic stockings after the surgery which has shown to decrease the risk of swelling and blood clots. Additionally, I use calf squeezers to keep the blood moving and that decreases the risk of blood clots after the surgery. I use regional anesthesia, which not only is better for pain control but also decreases the stasis, which again decreases the risk of blood clots. Intraoperatively, I minimize the rotation of the lower extremities so that the blood vessels don’t get kinked and therefore the risk of endothelial injury is reduced.
I also use frequent aspiration of the intramedullary canal and that minimizes the load of procoagulants into the venous saturation. The pharmacologic mainstay for decreasing the risk of blood clots after the surgery is Aspirin.
Why do you use aspirin and not other major potent anticoagulant drugs?
Strong anticoagulants increase the risk of major bleeding can lead to hematoma, which means formation of a blood clot. It can result in wound drainage. It can increase the risk of infection. Additionally, there is increased risk of nerve damage, increase in the risk of formation of calcium deposits in the joint, which can lead to a stiff joint. I use aspirin because it is helpful for the pain. It is helpful for the fever that may happen after the surgery.
Aspirin also protects against cardiovascular issues and peripheral vascular diseases. In addition, aspirin also can be administered orally. It has immediate action. There is no monitoring required and it is quite inexpensive.
What is Virchow’s triad?
Virchow’s triad includes the three factors that contribute to thrombosis: hypercoagulable state, stasis, and endothelial injury.
What is the difference between thrombosis and embolism?
Thrombosis means formation of a clot usually in the calf muscles of the lower extremity. Embolism means that clot has traveled to the lung.
What are the symptoms of embolism?
If a clot moves to the lung, symptoms may include chest pain, dizziness, rapid heartbeat, and shortness of breath. It has to be treated emergently. The patient needs to be taken to the hospital and needs to be evaluated. Further treatment may consist of administering strong blood thinners or placement of a net in the veins to prevent further travel of the blood clot into the lung. If the blood clot is extremely large it may need surgical evacuation.
What do you use to prevent blood clots after the surgery?
The most important thing that prevents blood clots is the patient getting up and walking. I like my patients to stand up and walk, or at least make an attempt to walk, the same day of surgery. Next day most patients are definitely walking with a walker and then the progress to walking with a cane.
I do not use any strong anti-coagulants, strong blood thinners for treating or for preventing blood clots, because literature is clear. It has shown that there are a lot of complications associated with them, like bleeding in the joint, bleeding elsewhere, especially in the brain. It is associated with increased morbidity and mortality. I use just aspirin, 325 mg of enteric coated aspirin. That has worked extremely well in my practice. It helps with pain relief and it also decreases the risk of blood clots.
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