The Journal of Arthroplasty Vol. 16 No.

6 2001

Venous Thromboembolic Disease Management

Patterns in Total Hip Arthroplasty and Total
Knee Arthroplasty Patients
A Survey of the AAHKS Membership

J. Wesley Mesko, MD,* Richard A. Brand, MD,† Richard Iorio, MD,‡

Ivan Gradisar, MD,§ Richard Heekin, MD,㛳 Ross Leighton, MD,¶
and Robert Thornberry, MD#

Abstract: The American Association of Hip and Knee Surgeons (AAHKS) distributed
a survey to its members exploring practice patterns implemented to prevent venous
thromboembolic disease (VTED) in patients undergoing total hip arthroplasty (THA)
and total knee arthroplasty (TKA). Of 720 (33%) members, 236 responded. Prophy-
laxis was prescribed for 100% of patients during the course of hospitalization for THA
and TKA. Warfarin was the commonest pharmacologic treatment used for THA
(66%) and TKA (59%) patients. Low-molecular-weight heparin was used in 16% of
THA patients and 18% of TKA patients. The most commonly employed mechanical
modality was pneumatic devices in THA (51%) and TKA (50%). Universal accep-
tance of the need for prophylaxis administration for patients undergoing THA and
TKA is shown. The method and duration remain highly variable; although the
survey illustrates such variation, it suggests there is no one best method of prophy-
laxis. Key words: venous thromboembolic disease, total hip arthroplasty, total knee
arthroplasty, prophylaxis, AAHKS.

Prevention of venous thromboembolic disease
(VTED) in the postoperative total joint arthroplasty
patient is a major focus of investigators, surgeons,
and the pharmaceutical industry. The impact of this
emphasis can be measured by the effort that sur-
From *Michigan State University, East Lansing, MI, †University of
Iowa Medical Center, Iowa City, IA, ‡Department of Orthopaedic
Surgery, Lahey Clinic Medical Center, Burlington, MA, §Akron, OH;
㛳Jacksonville, FL, ¶Halifax, NS, Canada, and #Tallahassee Orthopaedic
Clinic, Tallahassee, FL.
Submitted August 15, 2000; accepted March 30, 2001.
No benefits or funds were received in support of this study.
Reprint requests: J. Wesley Mesko, MD, Michigan Orthopedic
Center, 2901 Stabler Street, Lansing, MI 48910. E-mail:
WMESKO@JUNO.COM
Copyright © 2001 by Churchill Livingstone威
0883-5403/01/1606-0001$35.00/0
doi:10.1054/arth.2001.25506
geons exert to prevent these complications from oc-
curring. Surgeon behavior is modified by past experi-
ence with VTED, complications from prescribed
prophylactic and therapeutic means, and risk/benefit
analysis of prophylaxis versus VTED impact presented
in the literature. Practice patterns have been evalu-
ated in the general surgical and orthopaedic surgical
literature, revealing an increased use of some form of
prophylaxis in these specialties. Simon and Stengle in
1974 [1] and Paiement et al in 1987 [2] published
survey results showing a growing acceptance for
VTED prophylaxis in patients undergoing hip arthro-
plasty surgery during these 2 time periods. The
present study describes current opinions and practice
patterns regarding VTED prophylaxis of a group of
orthopaedic surgeons who perform high volumes of
joint arthroplasty surgery.

679
680 The Journal of Arthroplasty Vol. 16 No. 6 September 2001
Methods
A unique group of orthopaedic surgeons, who
performed a minimum of 50 THA and TKA opera-
tions per year and were members of the American
Association of Hip and Knee Surgeons (AAHKS),
were mailed a 15-question survey developed by the
AAHKS Research Committee. The American Acad-
emy of Orthopaedic Surgeons (AAOS) research de-
partment assisted in the survey design to facilitate
scanning and data tabulation (see Appendix). The
major elements of the questionnaire related to cur-
rent choices and duration of prophylaxis, surveil-
lance, management of high-risk patients, complica-
tions, and litigation related to VTED. We presume
many of the elements of this survey (eg, choice of
prophylaxis, litigation) are reasonably reliable be-
cause such practices do not change frequently or
quickly, and surgeons are not likely to forget litiga-
tion. Other elements, such as the frequency of
anticoagulation complications, are less reliable be-
cause they likely are reported as items of surgeon
recall. We report these later elements as ranges of
frequency of occurrence and only briefly. All of the
Society’s 720 members received this survey. Mem-
bers who failed to respond were sent a reminder. A
total of 236 (32.8%) completed surveys were re-
turned for analysis. The surveys were scanned, data
were tabulated, and preliminary analysis was pro-
vided by the AAOS Department of Research and
Scientific Affairs. The survey permitted an other—
describe response to many of the questions. In all
questions, this response was chosen infrequently
compared with the other options offered.
Results
Surgeon Demographics
The surgeon’s practice setting was an orthopaedic
group in 78% (183 of 236), a multispecialty group
in 14% (32 of 236), and solo practice in 9% (21 of
236). Of respondents, 76% (180 of 236) were in a
private practice environment, whereas 19% (46 of
236) were in an academic environment. Two per-
cent (5 of 236) were employees of a hospital, 2%
(4 of 236) were employees of a health maintenance
organization or prepaid plan, and 0.4% (1 of 236)
were employees of the U.S. government in the
armed services. Of respondents, 64% (150 of 236)
spent ⬎50% of their practice time performing THA
and TKA, whereas an additional 26% (62 of 236) of
the respondents reported ⬎30% of their practice
involved revision and complex joint arthroplasty;
17% (39 of 236) described joint arthroplasty com-
prising ⬍50% of their practice volume. The average
number of arthroplasties performed the year before
the survey was 81 hips and 103 knees (median, 75
hips and 80 knees).
Venous Thromboembolic Disease Routine
Surveillance and Prophylaxis
Routine screening for venous thrombosis was
infrequent. Of surgeons, ⬍1% (1 of 236) screened
only before surgery; 12% (28 of 236) screened only
before patient discharge; 5.6% (13 of 236) screened
before and after surgery. Of surgeons, 83.5% (198
of 236) did not screen routinely for VTED. Ultra-
sonography was used unanimously among sur-
geons who performed screening.
The type of anesthesia employed was believed to
be a contributing factor to the risk of postoperative
VTED by most respondents. Of surgeons, 90% (123
of 137) desired that patients have a regional anes-
thetic, with 50% (69 of 137) preferring spinal, 45%
(63 of 137) preferring epidural, 10% (14 of 137)
preferring a spinal– epidural combination, and 9%
(13 of 137) considering either spinal or epidural
acceptable. Twelve percent (16 of 137) believed
general anesthesia provided less risk for deep ve-
nous thrombosis.
THA patients were prescribed an average of 2.0
modalities of prophylaxis during the days of hospi-
talization. The most commonly prescribed prophy-
laxis regimens were warfarin (66.5% [155 of 233]),
pneumatic devices (50.6% [118 of 233]), and
thromboembolic disease (TED) stockings (42.9% [100
of 233]). Low-molecular-weight heparin (LMWH)
was prescribed for 15.4% (36 of 233), unfraction-
ated heparin was prescribed for 4.3% (10 of 233),
and aspirin was prescribed for 15.8% (37 of 233).
For surgeons who prescribed pneumatic stockings,
47.5% (56 of 118) used foot pumps, 22% (26 of
118) used knee-high devices, and 30.5% (36 of
118) used thigh-high devices. For surgeons who
prescribed TED stockings, 71% (71 of 100) pre-
ferred thigh-high stockings, whereas 29% (29 of
100) preferred knee-high stockings. Thigh-high
TED stockings frequently were worn in addition to
the pneumatic stockings and typically were em-
ployed for 23 h/d on both legs. All responding
surgeons prescribed some form of prophylaxis dur-
ing hospitalization after THA.
After hospital discharge following THA, 50%
(117 of 236) of the respondents prescribed warfa-
rin, 32.2% (76 of 236) prescribed aspirin, 9.3% (22
of 236) prescribed LMWH, and 4.7% (11 of 236)
prescribed no prophylaxis. Discharge prophylaxis,
for surgeons who prescribed it, was continued for
 Venous Thromboembolic Disease Management •
Fig. 1. Frequency of bleeding complications with the use of warfarin (Coumadin), aspirin (ASA), and low-molecular-
weight heparin (LMWH).
an average of 4.7 weeks (mean, 4 weeks). Of re-
spondents, 26.2% (44 of 168) of respondents in-
structed their patients to wear TED stockings, with
thigh-high stockings more popular than knee-high
stocking by 3:1. Patients were instructed to wear
the stockings for a mean of 16 h/d, for a mean of 28
days postdischarge.
TKA patients were prescribed an average of 2.0
modalities of prophylaxis while in the hospital. The
most commonly prescribed prophylaxis regimens
were warfarin (59.6% [139 of 233]), pneumatic
devices (50.2% [117 of 233]), and TED stockings
(41.6% [97 of 233]). LMWH was prescribed for
18% (42 of 233), unfractionated heparin was pre-
scribed for 4.3% (10 of 233), and aspirin was pre-
scribed for 18.4% (43 of 233). For surgeons who
prescribed pneumatic stockings, 50.4% (59 of 117)
used foot pumps, 25.6% (30 of 117) used knee-
high devices, and 24.8% (29 of 117) used thigh-
high devices. For surgeons who prescribed TED
Mesko et al. 681
stockings, 78.4% (76 of 97) preferred thigh-high
stockings, whereas 21.6% (21 of 97) preferred
knee-high stockings. As in THA patients, all re-
sponding surgeons prescribed at least 1 means of
prophylaxis while patients were hospitalized for
TKA. After hospital discharge following TKA,
44.1% (104 of 236) of the respondents prescribed
warfarin, 38.5% (91 of 236) prescribed aspirin,
11% (26 of 236) prescribed LMWH, and 6% (14 of
236) prescribed no prophylaxis.
Surgeons who prescribed warfarin sought to
maintain the patient’s international normalized ra-
tio (INR) at a median of 2.0 with a prothrombin
time of 16.0 seconds. Of surgeons who adminis-
tered warfarin on an outpatient basis, 69% (107 of
153) personally monitored and adjusted the INR
level. This monitoring was conducted weekly in
34% (46 of 134) and twice weekly in 39% (53 of
134) of responding surgeons who chose to follow
the levels. Of surgeons, 19% (28 of 153) delegated
682 The Journal of Arthroplasty Vol. 16 No. 6 September 2001
Fig. 2. Frequency of a hematoma with the use of warfarin (Coumadin), aspirin (ASA), and low-molecular-weight
heparin (LMWH).
this duty to a primary care provider, and the re-
maining 12% (19 of 153) gave other health care
providers this responsibility. Of the respondents,
61% (113 of 186) instructed their patients to limit
sitting in a chair to a median of 1 hour; 72% (132 of
184) limited riding in a car to a median of 1 hour.
These limitations were encouraged for a median of
6 weeks from surgery.
Management of Higher Risk Patients
Of surgeons, 74% (126 of 170) identified patients
with higher risk for postoperative VTED and mod-
ified their prophylaxis routine to provide what they
believed to be greater coverage than for patients
with less risk. Identified high-risk factors included
a past history of ⬎1 VTED episode (81% [145 of
180]) and past history of a single venous thrombotic
event with or without a documented pulmonary
embolus (54% [97 of 180]). Less commonly, obe-
sity, malignancy, clotting disorders, past history of
pulmonary embolus, advanced age, minimal mobil-
ity lifestyle, tobacco use, use of birth control pills,
family history of VTED, diabetes, and varicose veins
were identified as reasons to modify the routine
VTED prophylaxis patterns. Modified dosing and
duration of warfarin (73% [95 of 132]) was the
most frequently cited regimen for high-risk pa-
tients. Modifications included preoperative dosing,
more meticulous monitoring often delegated to an
internist, dosing to achieve a consistent INR of 2 to
3 postoperatively, or longer duration of prophy-
laxis. Of surgeons, 13% (17 of 132) employed pro-
longed treatment of LMWH, 25% (33 of 132) used
vena caval filter, and 9% (13 of 132) used unfrac-
tionated heparin, often given intravenously during
surgery. Stacked therapies were used more often,
combining pneumatic devices, fractionated hepa-
rin, or unfractionated heparin immediately postop-
eratively in a therapeutic dose concomitantly with
warfarin until the INR had risen to a therapeutic
range.
When a suspicion of deep venous thrombosis
arose, venous ultrasound was the most commonly
used investigative tool. Venograms were ordered
instead of ultrasound by 7.1% (12 of 169) of sur-
geons who suspected a thrombus proximal to the
trifurcation in the thigh. Venograms were ordered
less frequently instead of ultrasound by 3.1% (5 of
166) of surgeons who suspected a thrombus distal
to the trifurcation in the calf. If thrombi were iden-
 Venous Thromboembolic Disease Management •
Fig. 3. Frequency of delayed healing with the use of warfarin (Coumadin), aspirin (ASA), and low-molecular-weight
heparin (LMWH).
tified proximal to the knee, 61% (54 of 89) of the
surgeons referred patients to a primary care or
internal medicine physician for definitive manage-
ment. The remaining (39.3% [35 of 89]) personally
managed these patients, typically with warfarin
with a mean target INR of 2 for a mean of 12 weeks.
A few surgeons prescribed LMWH instead of war-
farin. If thrombi were identified as distal to the
knee, 40.2% (37 of 92) of surgeons referred the
patient to a primary care or internal medicine phy-
sician for definitive care. Of surgeons, 32.6% (30 of
92) treated with warfarin for a mean of 6 weeks
with an INR of 2.0. Twelve percent (11 of 92)
ignored the thrombi if there was no extension
above the knee, and 15% (14 of 92) took other
measures, such as a follow-up venous ultrasound
before taking further action or immediately pre-
scribed aspirin or LMWH.
Venous Thromboembolic Disease Prophylaxis
Complications
Complications from VTED prophylaxis appeared
to vary depending on the prophylaxis selected for
Mesko et al. 683
the total joint arthroplasty patient. Although bleed-
ing was perceived to be a rare complication of
aspirin therapy and infrequently seen with warfa-
rin, a higher incidence was perceived with the use
of LMWH (Fig. 1). The same pattern was perceived
for wound hematoma (Fig. 2) and delayed wound
healing (Fig. 3). The clinical manifestations of
thromboembolic events or fatal pulmonary embo-
lus were not perceived to be different between the
3 means of treatment (Figs. 4 and 5). Of surgeons,
39% (102 of 262) indicated that they currently
used the same prophylaxis regimen in THA and
TKA as they did 10 years ago. The remaining 61%
of surgeons listed an average of 1.2 reasons for
changing their prophylaxis-prescribing behavior. Of
surgeons, 27% (70 of 262) changed as a result of
complications observed from their previous pre-
scribed prophylaxis. Of surgeons, 24.4% (64 of
262) changed because of perceived improved cov-
erage with an alternative method. Only 1.5% (4
of 262) of surgeons changed as a result of man-
dates handed down by hospital, managed care, or
malpractice insurance mandates. Eleven percent
684 The Journal of Arthroplasty Vol. 16 No. 6 September 2001
Fig. 4. Frequency of deep venous thrombosis and pulmonary embolism incidents with the use of warfarin (Coumadin),
aspirin (ASA), and low-molecular-weight heparin (LMWH).
(29 of 262) changed for other reasons, including
lower cost, greater ease of administration, and
less monitoring. No differentiation was made
whether the changes of prophylaxis regimens
were for THAs only, TKAs only, or both surgeries.
This survey did not detect if multiple prophylaxis
changes had been made in THA or TKA in the
same 10-year interval.
Of surgeons, 7% (11 of 147) reported they had
faced litigation as a result of VTED in their patient.
Excessive anticoagulation resulted in legal action
taken by the patient toward the surgeon in 3% of
responding surgeons (5 of 160).
Of surgeons, 83% (150 of 180) prescribed pro-
phylactic measures as they chose, free of any man-
dates. The remaining surgeons identified their pre-
scribing practices as being regulated by hospital
orthopaedic departments, designated committees of
the orthopaedic department, hospital regulatory
committees, regional Medicare policy, or publicized
local lawyer association statements. One surgeon
named AAOS/AAHKS presentations as an authori-
tative source that strongly influences local deep
venous thrombosis prophylaxis policy.
Discussion
Many surveys of surgeon practices regarding
VTED prophylaxis have been published [1–5]. The
general surgical literature suggests an increased use
of prophylactic agents in more recent years com-
pared with earlier times in commonly performed
procedures among surgeons who responded to the
surveys. In 1982, Conti and Daschehbach [3] sent
994 general surgeons a survey that included 10
hypothetical clinical situations illustrating variable
risks of deep venous thrombosis and asked for the
prophylaxis the respondents would choose for each
of these patients. A total of 228 (30%) surgeons
responded to the survey. Of respondents, 73%
stated that available agents had not been proved
sufficiently effective, and 36% declared that bleed-
ing complications were excessive with antithrom-
boembolic agents. Most respondents chose the
same method of prophylaxis for all situations. Conti
and Daschehbach [3] concluded that only 19% of
the high-risk cases received effective prophylaxis.
In 1994 Caprini et al [4] surveyed 3,500 fellows
of the American College of Surgeons in the United
 Venous Thromboembolic Disease Management •
Fig. 5. Frequency of death occurring with the use of warfarin (Coumadin), aspirin (ASA), and low-molecular-weight
heparin (LMWH).
States and Canada. Of 1,018 (29.1%) respondents,
86% routinely prescribed some form of VTED pro-
phylaxis. Preferred modalities included intermittent
pneumatic compression devices, low-dose heparin,
and elastic stockings. Overall, 14% of the surgeons
used no prophylaxis modalities.
A similar trend of increased use of VTED prophy-
laxis over time is seen in the orthopaedic literature.
Simon and Stengle [1] reported in 1974 that 53% of
surgeons responding to their survey routinely pre-
scribed VTED prophylaxis in patients undergoing
THA. A 1987 survey by Paiement et al [2] of 288
general orthopaedic surgeons and 64 chiefs of ortho-
paedic surgery programs explored modalities used
during hospitalization to prevent DVT in patients un-
dergoing hip surgery. Respondents to the survey in-
cluded 19% of the general orthopaedic surgeons and
34% of the departmental chiefs (overall 21%). Of the
respondents, 84% routinely prescribed a pharmaco-
logic or mechanical modality (or both). Ten percent
prescribed pneumatic devices in high-risk patients
only, and 7% used no prophylaxis at all. Of the
general orthopaedic surgeons, 50% had prescribed
Mesko et al. 685
warfarin but discontinued it as a result of perceived
increased bleeding complications. Five percent of the
respondents routinely monitored postoperatively for
venous thrombosis. Nearly 19% of the community
orthopaedic surgeons and 29% of the program chiefs
reported that at least 1 of their patients died in the
perioperative period as a result of a suspected pulmo-
nary embolus after THA in the 5-year period before
the survey. This experience could not be converted
into an overall incidence because the total numbers of
deaths or the total numbers of THAs done in this time
frame were not reported.
The orthopaedic surgeons in this study performed
a high volume of THA and TKA surgery and re-
ported a higher percentage of prescription of VTED
prophylaxis in THA and TKA than the 2 previous
groups. Warfarin was the commonest means of
prophylaxis during the hospitalization and after dis-
charge for THA and TKA. Routine screening for
VTED was uncommon. LMWH is increasing in use,
but the perception of greater bleeding complica-
tions than with warfarin or aspirin lessens its po-
tential universal adoption at present [5–7].
686 The Journal of Arthroplasty Vol. 16 No. 6 September 2001

Table 1. Deep Venous Thrombosis Prophylaxis Practice Patterns of Orthopaedic Surgeons

Hip and Knee Society AAHKS

THA: Inpatient
64% (55/86) warfarin 67% (155/233) warfarin
15% (13/86) LMWH 15.4% (33/233) LMWH
21% (18/26) aspirin 16% (37/233) aspirin
76% (65/86) mechanical (TED stockings, pneumatic) 94% (218/233) mechanical (TED stockings, pneumatic)
TKA: Inpatient
62% (53/86) warfarin 60% (139/233) warfarin
14% (12/86) LMWH 18% (42/233) LMWH
18% (15/86) aspirin 18.4% (42/233) aspirin
78% (67/86) mechanical (TED stockings, pneumatic) 92% (214/233) mechanical (TED stockings, pneumatic)
1% (6/86) no prophylaxis use
Length of prophylaxis use For TKA For THA
38% (33/86) ⬍2 weeks 5 weeks average 4.7 weeks avarage
29% (25/86) 2–4 weeks 4 weeks median 4 weeks median
33% (28/86) ⬎–4 weeks
Postoperative screening for DVT
22% (19/86) routinely 8% (20/236) routinely screen before discharge
71% (61/86) only symptomatic patients 6% (13/236) other method
7% (6/86) never test 84% (198/236) do not screen
Anesthesia use*
46% (39/86) epidural/spinal regional 8% (11/137) regional
30% (20/86) epidural/spinal general 50% (69/137) spinal
24% (21/86) general 46% (63/137) epidural
10% (14/137) spinal/epidural
12% (16/137) general
1.5% (2/137) either
9% (13/137) does not matter

*For AAHKS, respondents may have picked more than one.

AAHKS, American Association of Hip and Knee Surgeons; THA, total hip arthroplasty; TKA, total knee arthroplasty; LMWH,
low-molecular-weight heparin; TED, thromboembolic disease; DVT, deep venous thrombosis.

A survey [8] of Hip Society and Knee Society
(HSKS) members concerning VTED prophylaxis af-
ter THA and TKA showed practice patterns that
were similar to the patterns presented in this study
(AAHKS) (Table 1). Routine venous thrombosis
surveillance was conducted more frequently with
HSKS members (22% [19 of 86]) compared with
AAHKS surgeons (8% [14 of 175]). HSKS surgeons
used venograms (9% [7 of 86]) and nuclear mag-
netic resonance imaging scans (2.5% [2 of 86])
more frequently than AAHKS surgeons did (0% for
both). AAHKS surgeons preferred regional anesthe-
sia more frequently (88% [123 of 139]) than HSKS
surgeons (76% [65 of 86]), although this difference
is not statistically significant.
The report of the fifth American College of Chest
Physicians consensus conference on antithrombotic
therapy [5] is a comprehensive review of available
modalities in 1998 considered to decrease the inci-
dence of VTED in patients undergoing THA and
TKA. This report discussed the common prescribing
patterns by surgeons of warfarin therapy in THA
patients, but pointed out the disadvantage of de-
layed therapeutic effectiveness until the 2nd or 3rd
day of administration. LMWH was reported to be
more effective in multicenter randomized prospec-
tive studies than warfarin in preventing in hospital
VTED [9 –12]. Other reports suggest LMWH to be
equally effective and more cost effective than war-
farin in lowering posthospitalization VTED follow-
ing THA [13,28]. Other studies reported a greater
risk of wound hematoma and bleeding with LMWH
over warfarin [6,10,11,14 –17]. The consensus re-
port [5] further suggested that VTED is more ubiq-
uitous in TKA and more resistant to prophylaxis
measures than in THA. Pneumatic compression de-
vices can be effective if applied intraoperatively,
and strict compliance is enforced to the bed-occu-
pying patient. Although adjusted-dose warfarin and
LMWH are deemed effective, the study concluded
that LMWH was more effective than warfarin, al-
though greater wound hematoma and bleeding
complications were found with LMWH. The lack of
monitoring and the rapid onset of action of LMWH
provide an advantage over the less expensive, easier
to administer, but significantly harder to regulate
and slower onset of effectiveness of warfarin.
Some investigators suggest that by using demon-
strable deep venous thrombosis as an endpoint in
clinical trials rather than death, the risk of clinically
significant thromboemboli may be exaggerated [18].
Given the rates of ⬍1 per 1,000 of fatal pulmonary
 Venous Thromboembolic Disease Management •
embolism [12,18 –27], low rates of reported recur-
rent deep venous thrombosis, and post-thrombotic
syndrome after total joint arthroplasty, some inves-
tigators have suggested that prevention of VTED in
patients without high risk may be related primarily
to rapid surgery, regional anesthetics, and rapid
mobilization [22,23]. Few investigators would con-
clude, however, that some form of pharmaceutical
treatment should not be included in the low-risk
populations [23,25]. For high-risk patients, phar-
macologic approaches undoubtedly will remain the
standard for the foreseeable future, and the choice
will depend on the particular situation and the
surgeon’s experience. Using death or clinically sig-
nificant deep venous thrombosis as an endpoint,
large prospective groups (20,000 – 65,000 patients)
would be necessary to give sufficient power to
determine optimal prophylaxis [26]. Until such de-
finitive multi-institutional trials are available, there
is no one best approach for all patients.
This study is based on a survey requiring surgeon
recall. We realize some of the elements (eg, numbers
of thromboembolic events and complications) of the
study are less reliable than others (eg, practice pat-
terns) because the former depend on recall, whereas
the latter depend on current practices (which do not
likely change frequently). This format encouraged a
high response rate from the AAHKS membership. The
end result is for the survey to be used as a typical
practice pattern among surgeons who do a higher
volume of joint arthroplasty surgery and not an en-
dorsement as to the correct means of treatment. This
does not mean that a cohort group of general ortho-
paedic surgeons who perform ⬍50 total joint arthro-
plasties per year may show a similar unanimous hos-
pital prescription of prophylaxis. The 33% response
rate is greater than similar studies we have considered
[1,2,8], yet it is insufficient to make statistically sig-
nificant conclusions as to true practice behaviors with
all joint arthroplasty surgeons. We suspect responders
did not answer questions when the questions did not
quite fit with their practice or when they believed the
question would require information not readily at
hand. This survey did not address dosing issues or
when the medication was given. The increased report
of postoperative bleeding, wound hematoma, and de-
layed healing with LMWH in Figs. 1 through 4 may
have been perceived differently if a comparison of
immediate postoperative administration and a 12-
hour delayed administration was performed.
The increased prescribing patterns of prophylaxis
reported in this study likely reflect the effect of resi-
dency and fellowship training, numerous peer review
articles, industry promotion of new products, and
litigation concerns that arose in the 1990s. Greater
Mesko et al. 687
understanding of patient factors present in clinically
significant VTED after THA or TKA has the potential
to allow targeted prophylaxis in the future and most
certainly would alter prescribing practice patterns again.
Acknowledgment
We thank the members of the AAHKS who com-
pleted and returned this survey, making this report
possible. We also thank Wanda Swenson for her
editorial assistance.
Appendix: AAHKS Deep Venous Thrombosis Survey
1. Principal practice type and setting
2. Degree of specialization (% of revisions and primaries)
3. Number of THAs and TKAs performed in 1998
4. What DVT prophylaxis agents do you commonly prescribe
for hospitalized THA patients? What DVT prophylaxis agent do
you commonly prescribe for hospitalized TKA patients?
5. Which of the following do you attempt to regulate in an
effort to decrease DVT rates? (type of surgical anesthesia,
encourage/discourage autologous blood donation, encourage/
discourage preoperative erythropoietin)
6. Do you routinely screen for DVT? If yes: What method do
you use? What do you do with a positive for DVT result above
the knee? What do you do with a positive for DVT result below
the knee?
7. Name your postdischarge DVT prophylaxis in TKA. How
long do you give it? Name your post discharge DVT
prophylaxis in THA. How long do you give it?
8. Do you limit the duration the patient can sit at one time?
If so: What is the maximum sedentary time that you advise?
How many weeks after the surgery does this time limit apply?
9. For those prescribing warfarin (Coumadin) for DVT
prophylaxis in the hospital: List your target INR/prothrombin
time. For those prescribing Coumadin for DVT prophylaxis
posthospitalization: List your target INR/prothrombin time. Who
follows the levels?
10. What is your routine diagnostic test when you have a
clinical suspicion on DVT? Have you ever faced malpractice
litigation concerning coagulation complications?
11. List frequency of complications experienced with the
following DVT prophylaxis methods: Coumadin, ASA, LMWH,
None, Other. If you changed to a different DVT prophylaxis
modality in the last 10 years, why did you change? Have you
ever faced malpractice litigation concerning anticoagulation
complications?
12. Do you routinely prescribe TED hose or a similar type of
graded compression stocking? What is the length of the
stocking? During hospital stay: How many hours in the day?
After hospital discharge: How many hours in the day? Number
of days?
13. Whom do you consider to be high-risk DVT patients? Do
you manage these people differently than those without high-
risk histories of DVT? If yes, how?
14. Do you have mandated directives concerning DVT
prophylaxis in your TKA and THA patients? If so: List the
sources of the directives.
15. State I practice in:
THA, total hip arthroplasty; TKA, total knee arthroplasty; DVT,
deep venous thrombosis; INR, international normalized ratio;
ASA, acetylsalicylic acid (aspirin); LMWH, low-molecular-
weight heparin; TED, thromboembolic disease.
688 The Journal of Arthroplasty Vol. 16 No. 6 September 2001
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