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Charles W. Francis, MD; Vincent D. Pellegrini, Jr, MD; Victor J. Marder, MD; Saara Totterman, MD; Carl M. Harris, MD; K. Ruben Gabriel, PhD; Michael V. Azodo, MD; Kristin M. Leibert

JAMA. 1992;267(21):2911-2915.

Abstract
Objective.
—To compare the effectiveness and safety of warfarin and external pneumatic compression (EPC) in prevention of venous thrombosis after total hip replacement.

Design.
—Prospective, randomized trial in consecutive patients, with blinded assessment of the primary end point.

Setting.
—University medical center and large community hospital.

Patients.
—Patients over age 18 years scheduled for elective primary total hip replacement were eligible. Of 254 patients interviewed, 232 were randomized, 220 patients had surgery and received prophylaxis, and 201 had venography.

Interventions.
—Patients were randomly assigned to prophylaxis with a device providing bilateral sequential EPC to both the calf and thigh or to receive warfarin in a low-intensity regimen beginning 10 to 14 days preoperatively. Prophylaxis was continued until venography.

Main Outcome Measures.
—Venous thrombosis was diagnosed by venography between postoperative days 6 and 8. Bleeding was assessed by surgical blood loss, transfusion requirements, changes in hematocrit, and clinically identified bleeding complications.

Results.
—The total incidence of venous thrombosis was virtually the same in the warfarin and EPC groups (31% vs 27%), but the distribution of thrombi was different. Proximal thrombosis occurred in 12% of patients in the EPC group compared with only 3% in the warfarin group (P=.012, 95% confidence interval for difference, 2% to 18%). In contrast, calf vein thrombosis was more frequent in the warfarin group (21%) than in the EPC group (12%) (P=.021,95% confidence interval for difference, 0% to 18%). Most proximal thrombi in EPC-treated patients were located within 15 cm of the femoral head and were not continuous with thrombi in deep calf veins. The high incidence of proximal thrombosis in the EPC group resulted in termination of the study by the safety monitoring committee. Blood loss and bleeding complications were similar in the two groups.

Conclusion.
—Warfarin therapy is significantly more effective than EPC in preventing serious proximal vein thrombosis after total hip replacement. The greater effectiveness of warfarin therapy in preventing proximal vein thrombi and of EPC in preventing thrombosis in the calf suggests that there are differences in the pathogenesis of thrombosis in these two locations.

(JAMA. 1992;267:2911-2915)

Author Affiliations
From the Hematology Unit, Department of Medicine (Drs Francis and Marder and Ms Leibert), and the Departments of Orthopaedics (Drs Pellegrini and Harris), Radiology (Drs Totterman and Azodo), and Statistics (Dr Gabriel), University of Rochester (NY) School of Medicine and Dentistry.

Footnotes
Reprint requests to Hematology Unit, PO Box 610, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY 14642 (Dr Francis).

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