Preoperative Versus Postoperative Initiation of Warfarin Therapy in Patients Undergoing Total Hip and Knee Arthroplasty

The optimal strategy for postoperative deep venous thrombosis prophylaxis remains controversial in hip and knee arthroplasty. Warfarin causes transient hypercoagulability; however, the optimal timing of treatment remains unclear. We evaluated the effects of preoperative versus postoperative warfarin therapy with a primary endpoint of perioperative change in hemoglobin. Warfarin was dosed according to a standard nomogram. No difference in perioperative hemoglobin change was observed. The preoperative group demonstrated higher INRs. Initiation of warfarin preoperatively was not associated with any difference in perioperative hemoglobin change. Larger studies are needed to determine whether the risk of adverse events is increased with either strategy.

  • We were unable to detect any difference in complication rates between groups.

  • We were unable to detect any difference in complication rates between groups.

  • After receiving appropriate Institutional Review Board approval, the electronic medical records for patients in the study population were retrospectively reviewed for INR levels (on POD 1 and 2), drain outputs (on POD 1, when all drains were removed), and change between preoperative and postoperative hemoglobin levels (on PODs 1 and 2). Patients were monitored clinically, but no Doppler studies or other screening modalities were performed to detect asymptomatic DVTs. The number of adverse events related to anticoagulation (wound healing complications, hematomas [abnormal swelling and fluid accumulation within the knee], epidural complications, and transfusions) or thrombosis (symptomatic DVT, pulmonary embolus) was also noted. These outcomes were compared between patient populations using a χ 2 test for categorical variables (wound healing complications, hematomas, and transfusions) and the Student t test for continuous variables (postoperative INR, drain output, and change between preoperative and postoperative hemoglobin levels). Adverse events (transfusions, hematomas, epidural complications, symptomatic DVT, and pulmonary embolus) were compared using the 2-tailed Fischer’s exact test.


    1. 1. Preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty: evidence-based guideline and evidence report. Rosemont (IL): American Academy of Orthopaedic Surgeons, 2011.

    2. 2. Markel D.C., York S., Liston M.J., et al: Venous thromboembolism: management by American Association of Hip and Knee Surgeons. J Arthroplasty 2010; 25: pp. 3-9.e1-2

    3. 3. Warwick D., and Rosencher N.: The “critical thrombosis period” in major orthopedic surgery: when to start and when to stop prophylaxis. Clin Appl Thromb Hemost 2010; 16: pp. 394-405

    4. 4. Arcelus J.I., Monreal M., Caprini J.A., et al: Clinical presentation and time-course of postoperative venous thromboembolism: results from the RIETE Registry. Thromb Haemost 2008; 99: pp. 546-551

    5. 5. Bjørnarå B.T., Gudmundsen T.E., and Dahl O.E.: Frequency and timing of clinical venous thromboembolism after major joint surgery. J Bone Joint Surg Br 2006; 88: pp. 386-391

    6. 6. Seagroatt V., Tan H.S., Goldacre M., et al: Elective total hip replacement: incidence, emergency readmission rate, and postoperative mortality. BMJ 1991; 303: pp. 1431-1435

    7. 7. White R.H., Romano P.S., Zhou H., et al: Incidence and time course of thromboembolic outcomes following total hip or knee arthroplasty. Arch Intern Med 1998; 158: pp. 1525-1531

    8. 8. Hull R.D., Brant R.F., Pineo G.F., et al: Preoperative vs postoperative initiation of low-molecular-weight heparin prophylaxis against venous thromboembolism in patients undergoing elective hip replacement. Arch Intern Med 1999; 159: pp. 137-141

    9. 9. Hull R.D., Pineo G.F., Stein P.D., et al: Timing of initial administration of low-molecular-weight heparin prophylaxis against deep vein thrombosis in patients following elective hip arthroplasty: a systematic review. Arch Intern Med 2001; 161: pp. 1952-1960

    10. 10. Kwong L.M., and Muntz J.E.: Thromboprophylaxis dosing: the relationship between timing of first administration, efficacy, and safety. Am J Orthop (Belle Mead NJ) 2002; 31: pp. 16-20

    11. 11. Perka C.: Preoperative versus postoperative initiation of thromboprophylaxis following major orthopedic surgery: safety and efficacy of postoperative administration supported by recent trials of new oral anticoagulants. Thromb J 2011; 9: pp. 17

    12. 12. Raskob G.E., and Hirsh J.: Controversies in timing of the first dose of anticoagulant prophylaxis against venous thromboembolism after major orthopedic surgery. Chest 2003; 124: pp. 379S-385S

    13. 13. Strebel N., Prins M., Agnelli G., et al: Preoperative or postoperative start of prophylaxis for venous thromboembolism with low-molecular-weight heparin in elective hip surgery? Arch Intern Med 2002; 162: pp. 1451-1456

    14. 14. Tribout B., and Colin-Mercier F.: New versus established drugs in venous thromboprophylaxis: efficacy and safety considerations related to timing of administration. Am J Cardiovasc Drugs 2007; 7: pp. 1-15

    15. 15. Esmon C.T., Vigano-D’Angelo S., D’Angelo A., et al: Anticoagulation proteins C and S. Adv Exp Med Biol 1987; 214: pp. 47-54

    16. 16. Vigano D’Angelo S., Comp P.C., Esmon C.T., et al: Relationship between protein C antigen and anticoagulant activity during oral anticoagulation and in selected disease states. J Clin Invest 1986; 77: pp. 416-425

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    Feb 23, 2017 | Posted by in ORTHOPEDIC | Comments Off on Preoperative Versus Postoperative Initiation of Warfarin Therapy in Patients Undergoing Total Hip and Knee Arthroplasty
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