LETTER
Hypercoagulability after Hip and Knee Replacement
Eddys Disla, MD
15 March 1994 | Volume 120 Issue 6 | Page 523
TO THE EDITOR:
The excellent review on hypercoagulable states [1] did not include a discussion of hip and knee replacement, which represents the most important hypercoagulable state. Deep-vein thrombosis occurs in 40% to 70% of patients in the absence of anticoagulation [2].
Current preventive strategies are disappointing, with rates of deep-vein thrombosis of over 30% [2]. The use of heparin and warfarin is limited by the high risk for bleeding after surgery.
Nachman and Silverstein [1] remind us of the intricate relation between inflammation and clotting; they suggest that endothelial activation by cytokines leads to loss of anticoagulant function with conversion to a pro-inflammatory thrombogenic phenotype.
Could anti-inflammatory agents such as aspirin or glucocorticoids be used to enhance the anticoagulant effect of heparin or warfarin without increasing the risk for bleeding? Pooled results of aspirin studies indicate that the risk reduction for deep-vein thrombosis after hip replacement is small [3].
A recent study [4] found that high-dose glucocorticoids enhanced the procoagulant state after hip replacement. A protective effect against deep-vein thrombosis could come from endothelial changes such as suppression of adhesion molecules [5] rather than affecting clotting profile. The role of anti-inflammatory agents in the prophylaxis of deep-vein thrombosis is still unsettled, but it certainly deserves further exploration.
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Author and Article Information
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Cabrini Medical Center; New York, NY 10003
1. Nachman RL, Silverstein R. Hypercoagulable states. Ann Intern Med. 1993; 119:819-27.
2. Verstraete M. The diagnosis and treatment of deep-vein thrombosis. N Engl J Med. 1993; 329:1418-20.
3. Clagett GP, Anderson FA Jr, Levine MN, Salzman EW, Wheeler HB. Prevention of venous thromboembolism. Chest. 1992; 102:391S-407S.
4. Hogevold HE, Lyberg T, Kierulf P, Reikeras O. Generation of procoagulant (thromboplastin) and plasminogen activator activities in peripheral blood monocytes after total hip replacement surgery. Effects of high doses of corticosteroids. Thrombosis Res. 1991; 62:449-57.
5. Tessier P, Audette M, Cattaruzzi P, McColl SR. Up-regulation by tumor necrosis factor 
of intercellular adhesion molecule 1 expression and function in synovial fibroblasts and its inhibition by glucocorticoids. Arthritis Rheum. 1993; 36:1528-39.
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