Does a patient who has undergone a right total knee arthroplasty (TKA) revision with patellar tendon repair require Deep Vein Thrombosis (DVT) prophylaxis upon discharge?

DVT Prophylaxis After Right Total Knee Arthroplasty Revision with Patellar Tendon Repair

Yes, a patient who has undergone a right total knee arthroplasty revision with patellar tendon repair should receive DVT prophylaxis upon discharge. This recommendation is based on the high risk of venous thromboembolism (VTE) associated with major orthopedic procedures and the need for continued protection during the recovery period.

Risk Assessment and Rationale

Total knee arthroplasty (TKA) revision surgery carries a significant risk of VTE complications:

• Major orthopedic surgeries, including TKA revisions, are considered high-risk procedures for VTE development
• The additional patellar tendon repair may further increase immobility and risk factors
• The risk of VTE persists beyond the inpatient stay, with many events occurring after discharge

Recommended Prophylaxis Approach

For Standard Risk Patients:

• Pharmacological prophylaxis: LMWH (low molecular weight heparin) or fondaparinux is preferred over unfractionated heparin 1
• Duration: Continue for at least 10-14 days post-operatively 2
• Alternative option: Aspirin (325mg twice daily) may be considered for patients with standard VTE risk profile 3

For High-Risk Patients:

• Extended prophylaxis: Consider extending pharmacological prophylaxis up to 28-35 days 2
• Combination approach: Consider combining mechanical and pharmacological methods for patients at high risk for thrombosis 1

For Patients with High Bleeding Risk:

• Mechanical prophylaxis: Use intermittent pneumatic compression devices rather than pharmacological methods 1
• Reassess: Convert to pharmacological prophylaxis when bleeding risk decreases

Evidence Supporting Post-Discharge Prophylaxis

The ACCP guidelines specifically recommend thromboprophylaxis for at least 10-14 days following major orthopedic surgery 1. For TKA specifically, the evidence suggests:

• The risk of symptomatic VTE continues after hospital discharge
• Early mobilization alone is insufficient to prevent post-discharge VTE events
• Studies show that extended prophylaxis reduces the risk of symptomatic DVT compared to shorter courses 1

Important Considerations and Caveats

1. Patellar tendon repair impact: The patellar tendon repair component may limit early mobilization, potentially increasing VTE risk and supporting the need for continued prophylaxis

2. Bleeding risk assessment: Always weigh the risk of bleeding against the risk of thrombosis before prescribing pharmacological prophylaxis

3. Mechanical methods alone: Not recommended as monotherapy unless there is a high risk of bleeding 1

4. Monitoring requirements: If using LMWH or fondaparinux, no routine monitoring is required; if using warfarin, INR monitoring is necessary

5. Compliance considerations: Assess the patient's ability to self-administer injections or take oral medications reliably

Conclusion

Based on current guidelines and evidence, DVT prophylaxis should be continued after discharge for patients who have undergone right total knee arthroplasty revision with patellar tendon repair. The specific agent and duration should be selected based on the patient's individual risk factors for both thrombosis and bleeding, with a minimum duration of 10-14 days post-operatively.