Is Rivaroxaban Superior to Enoxaparin in Preventing Post- Operative Venous Thromboembolism following Total Knee or Hip Arthroplasty

Is Rivaroxaban Superior to Enoxaparin in Preventing Post- Operative Venous Thromboembolism following Total Knee or Hip Arthroplasty?

Submitted by:
Lopa Patel, PAS-2
Salus University Physician Assistant Program

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Karyn MacQueen, MMS, PA-C
Salus University Physician Assistant Program

A Capstone Project Proposal prepared for the Salus University Physician Assistant Program
In partial fulfillment of the requirements for the
Degree of Master of Medical Science in Physician Assistant Studies
Submitted: July 6, 2018


I. Abstract
i. Objective
ii. Methods
iii. Results
iv. Conclusion
II. Introduction
i. Prevalence of venous thromboembolism (VTE) worldwide after total knee or orthopedic surgery
ii. Current Guidelines on management of VTE
1. The American College of Chest Physician (ACCP) from 2012
2. The American Academy of Orthopedic Surgeon (AAOS) from 2011
iii. Compare and contrast enoxaparin vs. rivaroxaban
III. Methods
i. Search engines
1. Salus Total Search Article Databases and PubMed
ii. Search Terms
1. rivaroxaban versus enoxaparin, venous thromboembolism, prevention/prophylaxis total knee arthroplasty, total hip arthroplasty
iii. Exclusion and inclusion criteria
iv. Reliability and validity of articles
a. VTE overview
a. Most common and fatal complication is venous thromboembolism (VTE).
a. Epidemiology/Etiology
i. Incidence of VTE after total knee or hip arthroplasty is as high as 30-60% in absence of prophylactic anticoagulation.
b. Pathophysiology of VTE
i. Virchow’s Triad includes endothelial damage, venous stasis and hypercoagulable state.
ii. These three factors are strongly associated with post-op complication of orthopedic surgeries; especially, total knee or hip arthroplasties.
iii. Coagulation cascade
iv. Low ATIII levels in orthopedic surgery
c. Risk factors of VTE
i. High risk
1. Recent major orthopedic surgery/arthroplasty/or fracture
2. Abdominal/pelvic cancer undergoing surgery
3. Recent spinal cord injury or major trauma within 90 days
ii. Intermediate risk
1. Not ambulating independently outside of room at least twice daily
2. Active infectious or inflammatory process
3. Active malignancy
4. Major non-orthopedic surgery
5. Prior immobilization (; 72 hours) preoperatively
6. Obesity (BMI ; 30)
7. Patient age ; 50 years
8. Hormone replacement or oral contraceptive therapy
9. Hypercoagulable state
10. Nephrotic syndrome
11. Burns
12. Varicose veins
iii. Low risk
1. Minor procedure and age ; 40 years with no additional risk factors
2. Ambulatory with expected length of stay of 72 hours) preoperatively, major non-orthopedic surgery, hormone replacement or oral contraceptive therapy, sepsis/inflammatory process/malignancy, nephrotic syndrome or hypercoagulable state. 11-13 Low risks of VTE includes minor surgical procedures with non-abulatory for