This handout is for post-orthopedic-arthroplasty dvt (post-tha/tka/hip-fracture; asa vs doac vs lmwh per aaos 2025 + accp). Your care team identified this based on: unilateral lower-extremity swelling, calf pain, or whole-leg swelling within 4-6 weeks of tha / tka / hip-fracture surgery — post-arthroplasty vte pretest probability sharply elevated.
Other reasons your team may use this plan: documented tha / tka / hip-fracture-surgery within preceding 6 weeks — anchor the surgical provoking factor and prophylaxis history (regimen + adherence + duration completed); new pleuritic chest pain, dyspnea, syncope, hemoptysis, or unexplained tachycardia within 35 days of tha / hip-fracture surgery (12 days for tka) — concurrent pe screen mandated; ctpa if wells pe > 4 or perc fail; incidental dvt identified on post-op ct (e.g., for fever workup or pe screen) in arthroplasty patient — confirm + manage per symptomatic vs surveillance distinction.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| apixaban | Treatment: 10 mg BID × 7 d → 5 mg BID × 3 mo; Extended prophylaxis: 2.5 mg BID × 35 d post-THA or × 12 d post-TKA per ADVANCE-2/3 | PO | BID | Treatment: AMPLIFY (Agnelli NEJM 2013 PMID 23808982) — apixaban first-line for established VTE; Prophylaxis: ADVANCE-2 (Lassen Lancet 2010 PMID 20206776) and ADVANCE-3 (Lassen NEJM 2010 PMID 21142528) — 2.5 mg BID superior to enoxaparin for prophylaxis; AAOS 2025 + ACCP 2021 first-line option |
| rivaroxaban | Treatment: 15 mg BID × 21 d → 20 mg daily × 3 mo; Extended prophylaxis: 10 mg daily × 35 d post-THA or × 12 d post-TKA per RECORD-1/2/3 | PO | BID then daily; 10 mg daily for prophylaxis | Treatment: EINSTEIN-DVT (Bauersachs NEJM 2010 PMID 21128814); Prophylaxis: RECORD-1/2/3 (Eriksson NEJM 2008 PMID 18579812; Kakkar Lancet 2008 PMID 18582928; Lassen NEJM 2008 PMID 18579811) — rivaroxaban 10 mg daily superior to enoxaparin for prophylaxis; EPCAT-II (Anderson NEJM 2018 PMID 29466159) — ASA non-inferior to rivaroxaban for symptomatic VTE prevention after 5-d rivaroxaban lead-in |
| aspirin | Prophylaxis: 81 mg PO BID × 30 d post-THA or × 14 d post-TKA after 5-day rivaroxaban or enoxaparin lead-in (per AAOS 2025 + EPCAT-II; standard-risk patients only) | PO | BID for prophylaxis (NOT for symptomatic DVT treatment) | EPCAT-II (Anderson NEJM 2018 PMID 29466159) — ASA 81 mg BID after 5-d rivaroxaban lead-in NON-INFERIOR to continued rivaroxaban for symptomatic VTE prevention after THA/TKA; AAOS 2025 Strong recommendation in standard-risk patients; do NOT use ASA monotherapy in high-risk patients (prior VTE, active cancer, thrombophilia, BMI >40, hip-fracture surgery); never substitute for treatment-dose AC in symptomatic established DVT |
| enoxaparin | Treatment: 1 mg/kg SC BID (1 mg/kg daily if CrCl <30); Prophylaxis: 40 mg SC daily (THA/TKA) or 30 mg SC q12h (HFS or extended); 35-d post-THA or 12-d post-TKA | SC | BID treatment; daily or q12h prophylaxis | ASH 2020 (PMID 33007077); ACCP 2021; AAOS 2025 — LMWH first-line option for high-risk arthroplasty patients and HFS; pre-op LMWH considered if HFS surgery delayed >12 h per HIP-ATTACK (Borges Lancet 2020 PMID 32325025) |
| dabigatran | Prophylaxis: 220 mg PO daily after 1-4 h post-op half-dose start × 35 d (THA) or × 10 d (TKA) per RE-NOVATE / RE-MODEL | PO | daily | RE-NOVATE / RE-MODEL — dabigatran 220 mg daily non-inferior to enoxaparin for prophylaxis; less commonly chosen than apixaban or rivaroxaban; CrCl <30 contraindication |
| warfarin | 5 mg daily; INR target 2-3 for treatment of established post-op DVT; for prophylaxis target INR 1.8-2.2 (less commonly used since DOAC era) | PO | daily | TRAPS (Pengo Blood 2018) — warfarin > rivaroxaban in triple-positive APS; reasonable alternative if DOAC contraindicated; CrCl <15 → warfarin only; mechanical heart valve patients undergoing arthroplasty need warfarin bridge planning |
| heparin | 80 U/kg IV bolus + 18 U/kg/h targeting aPTT 1.5-2.5× | IV | continuous | Reversibility for acute peri-procedural management; ACCP 2021; reasonable for patients with planned return to OR or active bleed risk requiring rapid AC reversal |
| intermittent pneumatic compression (IPC) | Continuous IPC bilateral lower extremities while in hospital (or non-operated leg if surgical-site precludes ipsilateral) | mechanical | continuous in hospital | CLOTS-3 (Dennis Lancet 2013 PMID 23484795) — IPC reduces DVT in immobile patients; ACCP 2021 + AAOS 2025 — universal in-hospital adjunct; may serve as primary prophylaxis if pharmacologic AC contraindicated |
| fondaparinux | Prophylaxis: 2.5 mg SC daily × 35 d post-THA or × 12 d post-TKA starting 6-8 h post-op (PENTHIFRA / EPHESUS) | SC | daily | PENTHIFRA / EPHESUS — fondaparinux non-inferior to enoxaparin for arthroplasty prophylaxis; HIT-safe alternative; renal contraindication CrCl <30 |
Plan: Post-arthroplasty DVT — treatment-dose AC for symptomatic post-op DVT (3 mo provoked) PLUS framework for extended prophylaxis (35 d hip / 12 d knee per AAOS 2025 + ACCP 2021) and risk-tiered drug choice (ASA non-inferior to DOAC for standard-risk per EPCAT-II)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
STOP AC at 3 mo for provoked-by-reversed-factor presentation per ACCP 2021; 6-wk orthopedic follow-up confirms substrate reversal (ambulatory, prosthesis healed); future arthroplasty (contralateral or revision) requires the same extended-prophylaxis cycle; reinforce future-surgical-prophylaxis awareness; cardiac rehab if HFS in elderly patient
Guideline: AAOS 2025 VTE Prophylaxis Post-Arthroplasty + ACCP/CHEST 2021 (Stevens) + RECORD program + EPCAT-II + ASRA 2018 neuraxial AC