Is Pharmacologic Prophylaxis for Venous Thromboembolism Necessary in People With Hemophilia After Total Knee and Hip Arthroplasty?

Pharmacologic thromboprophylaxis for postoperative venous thromboembolism (VTE) after total knee arthroplasty (TKA) and total hip arthroplasty (THA) in people with hemophilia (PWH) is highly controversial. In PWH the prevalence of symptomatic VTE after TKA and THA is between 0 to 5%, while the prevalence of asymptomatic VTE is between 7.5% and 10%. In PWH many clinicians have not used pharmacologic thromboprophylaxis. Others have used low molecular weight heparin (LMWH) and reduced doses of DOAC [direct oral anticoagulants (thrombin inhibitors and Factor Xa inhibitors)]. It appears that pharmacologic thromboprophylaxis should only be carried out in PWH undergoing TKA and THA who have VTE risk factors [e.g., old age, prior VTE, varicose veins, general anesthesia, cancer, Factor V (Leiden) mutation, and obesity]. After TKA and THA in PWH, early mobilization is essential. Some authors have advocated additional mechanical thromboprophylaxis (pneumatic compression devices). In conclusion, for all PWH experiencing TKA and THA mechanical prophylaxis is sensible. Some form of pharmacologic prophylaxis should be strongly considered for PWH with clear risk factors. The main area of doubt is in PWH without risk factors. More prospective multicenter studies are required. Difficulties will be getting agreement on universal regimes to be followed; and the relatively small numbers of PWH experiencing TKA and THA.