Abstract
Thromboembolic (TE) events and related wound issues are the most common post-operative complications related to lower extremity total joint arthroplasty. They represent not only significant morbidity but also serious economic consequences. Evolution has selected for thrombus formation as a protection against exsanguination. Trauma is by definition a thrombogenic event. As surgery is an elective trauma, it is understandable that an individual undergoing a surgical procedure will be at increased risk to develop a TE event. However, to treat all patients with an identical prophylaxis denies the reality that the population is not homogeneous. Rather it is a normal distribution with wide variability from hemophyllic to thrombophyllic. As a consequence some patients may be over treated with resultant wound complications, i.e. hematomas, drainage, delaying discharge or worse requiring re-admisssion, re-operation or worst of all a secondary infection of the implanted device.
For this reason we proposed an inexpensive pre-operative screening protocol to more objectively identify an individual's levelof thrombophyllia. Although not exhaustive, it identifies those patients at ends of the curve with either an increased risk of clot or bleeding. It includes: Factor VIII, Factor V (Leyden), Factor C (APCR), Fibrinogen, D-dimer, Prothrombin Gene Mutation, ESR and CRP. This protocol costs less than $200/patient and was found to be 100% predictive of patient risk. Since instituting this protocol we have eliminated re-admission for complications related to overly aggressive TE prophylaxis. It has become an invaluable and intergral part of our pre-, intra- and post-operative protocol for multimodal TE prophylaxis.
