Graham S. Goh, Leanne Ludwick, Yoshi P. Djaja.
Response/Recommendation: Patients undergoing SBTHA are at a higher risk of venous thromboembolism (VTE) compared to those undergoing unilateral total hip arthroplasty (THA). Chemoprophylaxis should be considered for these patients, although the optimal agent remains uncertain.
Strength of Recommendation: Limited.
Rationale: A SBTHA has demonstrated several advantages in carefully selected patients, including the need for only one anaesthetic, reduced length of stay and decreased perioperative costs1–3. Although one recent meta-analysis reported lower rates of major systemic complications and deep venous thrombosis (DVT) in SBTHA4, and comparable rates of pulmonary embolism (PE) and mortality between simultaneous and staged procedures, there is ample evidence to suggest that single-stage bilateral THA is associated with a greater risk of VTE due to the an increased volume of procoagulants forced into the venous circulation from the intramedullary canal as well as the prolonged operative time causing venous stasis5,6. A vast body of literature has reported an increased risk of VTE following simultaneous bilateral compared to unilateral THA7–13.
The most recent guidelines from the American Academy of Orthopaedic Surgeons (AAOS), American College of Chest Physicians (ACCP) and National Institute or Health and Clinical Excellence (NICE) do not specify the optimal VTE prophylactic agent for patients undergoing SBTHA14–16. While aspirin has been established as an effective chemoprophylaxis option with a favorable safety profile compared to more aggressive anticoagulants17, it remains uncertain whether VTE prophylaxis selection should be individualized on the basis of the risk profile of the patient. The guidelines by the AAOS similarly emphasized the importance of risk stratification but was unable to offer guidance on such stratification15.
Current literature lacks consensus regarding the most appropriate VTE prophylactic agent for patients undergoing simultaneous bilateral joint replacements. Previous studies comparing different agents examined heterogenous cohorts containing both unilateral and bilateral THA18–20. In addition, another study compared the efficacy of aspirin with that of other anticoagulants only after risk-stratifying unilateral cases into a “low-risk” group that received aspirin, and bilateral cases into a “high-risk” group that received potent anticoagulants, thus making it difficult to make a valid comparison21. While a few retrospective studies have examined the efficacy of different chemoprophylactic agents following simultaneous bilateral total knee arthroplasty22,23, only one study has been performed in THA literature24. Beksaç et al., retrospectively analyzed 644 patients who underwent SBTHA followed by a multimodal prophylaxis protocol. Importantly, the authors found no significant difference in the rates of symptomatic VTE (6.2% vs. 5.7%), PE (1.4% vs. 1.1%), DVT (7.0% vs. 5.7%) between the warfarin (n=292) and aspirin (n=352) groups. There were two deaths in each group, neither of which were related to VTE24.
While it is widely acknowledged that bilateral joint replacements are associated with a greater VTE risk, there is a paucity of evidence on the optimal prophylactic agent following these procedures. Therefore, we recommend that routine chemoprophylaxis, including aspirin as well as more potent anticoagulants, should be considered for all patients undergoing SBTHA. Future comparative trials are needed to address this issue.
1. Reuben JD, Meyers SJ, Cox DD, Elliott M, Watson M, Shim SD. Cost comparison between bilateral simultaneous, staged, and unilateral total joint arthroplasty. J Arthroplasty. 1998;13(2):172-179. doi:10.1016/s0883-5403(98)90095-x
2. Parvizi J, Tarity TD, Sheikh E, Sharkey PF, Hozack WJ, Rothman RH. Bilateral total hip arthroplasty: one-stage versus two-stage procedures. Clin Orthop Relat Res. 2006;453:137-141. doi:10.1097/01.blo.0000246529.14135.2b
3. Kim Y-H, Kwon O-R, Kim J-S. Is one-stage bilateral sequential total hip replacement as safe as unilateral total hip replacement? J Bone Joint Surg Br. 2009;91(3):316-320. doi:10.1302/0301-620X.91B3.21817
4. Shao H, Chen C-L, Maltenfort MG, Restrepo C, Rothman RH, Chen AF. Bilateral Total Hip Arthroplasty: 1-Stage or 2-Stage? A Meta-Analysis. J Arthroplasty. 2017;32(2):689-695. doi:10.1016/j.arth.2016.09.022
5. Berend ME, Ritter MA, Harty LD, et al. Simultaneous bilateral versus unilateral total hip arthroplasty an outcomes analysis. J Arthroplasty. 2005;20(4):421-426. doi:10.1016/j.arth.2004.09.062
6. Ritter MA, Stringer EA. Bilateral total hip arthroplasty: a single procedure. Clin Orthop Relat Res. 1980;(149):185-190.
7. Zhang Z, Shen B, Yang J, Zhou Z, Kang P, Pei F. Risk factors for venous thromboembolism of total hip arthroplasty and total knee arthroplasty: a systematic review of evidences in ten years. BMC Musculoskelet Disord. 2015;16:24. doi:10.1186/s12891-015-0470-0
8. Parvizi J, Huang R, Rezapoor M, Bagheri B, Maltenfort MG. Individualized Risk Model for Venous Thromboembolism After Total Joint Arthroplasty. J Arthroplasty. 2016;31(9 Suppl):180-186. doi:10.1016/j.arth.2016.02.077
9. Cronin M, Dengler N, Krauss ES, et al. Completion of the Updated Caprini Risk Assessment Model (2013 Version). Clin Appl Thromb Hemost. 2019;25:1076029619838052. doi:10.1177/1076029619838052
10. Trojani C, d’Ollonne T, Saragaglia D, et al. One-stage bilateral total hip arthroplasty: functional outcomes and complications in 112 patients. Orthop Traumatol Surg Res. 2012;98(6 Suppl):S120-123. doi:10.1016/j.otsr.2012.06.008
11. Virtanen L, Salmela B, Leinonen J, et al. Laboratory-monitored fondaparinux and coagulation activity in association with total hip replacement. Blood Coagul Fibrinolysis. 2014;25(6):597-603. doi:10.1097/MBC.0000000000000116
12. Yeager AM, Ruel AV, Westrich GH. Are bilateral total joint arthroplasty patients at a higher risk of developing pulmonary embolism following total hip and knee surgery? J Arthroplasty. 2014;29(5):900-902. doi:10.1016/j.arth.2013.11.001
13. Won M-H, Lee G-W, Lee T-J, Moon K-H. Prevalence and risk factors of thromboembolism after joint arthroplasty without chemical thromboprophylaxis in an Asian population. J Arthroplasty. 2011;26(7):1106-1111. doi:10.1016/j.arth.2010.11.005
14. Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e278S-e325S. doi:10.1378/chest.11-2404
15. Jacobs JJ, Mont MA, Bozic KJ, et al. American Academy of Orthopaedic Surgeons clinical practice guideline on: preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Bone Joint Surg Am. 2012;94(8):746-747. doi:10.2106/JBJS.9408.ebo746
16. National Guideline Centre (UK). Venous Thromboembolism in over 16s: Reducing the Risk of Hospital-Acquired Deep Vein Thrombosis or Pulmonary Embolism. National Institute for Health and Care Excellence (UK); 2018. Accessed August 23, 2021. http://www.ncbi.nlm.nih.gov/books/NBK493720/
17. Parvizi J, Ceylan HH, Kucukdurmaz F, Merli G, Tuncay I, Beverland D. Venous Thromboembolism Following Hip and Knee Arthroplasty: The Role of Aspirin. J Bone Joint Surg Am. 2017;99(11):961-972. doi:10.2106/JBJS.16.01253
18. Odeh K, Doran J, Yu S, Bolz N, Bosco J, Iorio R. Risk-Stratified Venous Thromboembolism Prophylaxis After Total Joint Arthroplasty: Aspirin and Sequential Pneumatic Compression Devices vs Aggressive Chemoprophylaxis. J Arthroplasty. 2016;31(9 Suppl):78-82. doi:10.1016/j.arth.2016.01.065
19. Intermountain Joint Replacement Center Writing Committee. A prospective comparison of warfarin to aspirin for thromboprophylaxis in total hip and total knee arthroplasty. J Arthroplasty. 2012;27(1):1-9.e2. doi:10.1016/j.arth.2011.03.032
20. Yu X, Wu Y, Ning R. The deep vein thrombosis of lower limb after total hip arthroplasty: what should we care. BMC Musculoskelet Disord. 2021;22(1):547. doi:10.1186/s12891-021-04417-z
21. Vulcano E, Gesell M, Esposito A, Ma Y, Memtsoudis SG, Gonzalez Della Valle A. Aspirin for elective hip and knee arthroplasty: a multimodal thromboprophylaxis protocol. Int Orthop. 2012;36(10):1995-2002. doi:10.1007/s00264-012-1588-4
22. Nam D, Nunley RM, Johnson SR, Keeney JA, Barrack RL. Mobile compression devices and aspirin for VTE prophylaxis following simultaneous bilateral total knee arthroplasty. J Arthroplasty. 2015;30(3):447-450. doi:10.1016/j.arth.2014.10.018
23. Goel R, Fleischman AN, Tan T, et al. Venous thromboembolic prophylaxis after simultaneous bilateral total knee arthroplasty: aspirin versus warfarin. Bone Joint J. 2018;100-B(1 Supple A):68-75. doi:10.1302/0301-620X.100B1.BJJ-2017-0587.R1
24. Beksaç B, González Della Valle A, Anderson J, Sharrock NE, Sculco TP, Salvato EA. Symptomatic thromboembolism after one-stage bilateral THA with a multimodal prophylaxis protocol. Clin Orthop Relat Res. 2007;463:114-119.