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In global admission studies (RECORD I-IV) Rivaroxaban and enoxaparin as a standard prophylaxis were comparable in safety of treatment, but rivaroxaban appeared more effective in prevention of venous thromboembolism (VTE) when used in elective hip and knee replacement. The worldwide non-interventional cohort study XAMOS confirmed these results in the clinical routine compared to proven anticoagulants.Efficacy and safety of rivaroxaban was to be compared with the standard prophylaxis in the prevention of VTE after elective hip and knee replacement surgery in clinical practice in Germany. For this purpose a subanalysis of the 2,719 patients (XAMOS-DE) included in XAMOS in German study centers was performed.Out of 2,719 patients in 32 study centers 1,333 patients obtained rivaroxaban and 1,386 patients obtained standard prophylaxis. The incidence of symptomatic VTE-events (0.9% with rivaroxaban vs. 1.1% with standard prophylaxis) and severe bleeding by RECORD (0.5% vs. 0.9%) and EMA criteria (2.9 % vs. 3.0%) was similar in both groups. Most of the patients treated with rivaroxaban rated tolerability as "very good" and therapy as "very patient-friendly".The results from XAMOS-DE confirm in clinical practice the favorable benefit-risk ratio of rivaroxaban, as well as the current S3 guidelines for thromboembolism prophylaxis with rivaroxaban in elective hip and knee replacement.

Recent findings require an update of earlier recommendations on the perioperative management of non Vitamin K antagonist oral anticoagulants (NOAC).The present position paper summarises the outcomes of an expert panel discussion.Based on the pharmacokinetic profile of rivaroxaban, a preoperative interruption of 24-72 hours is recommended depending on the patient's renal function, as well as individual and surgery-related bleeding risks. Similar NOAC-free intervals are recommended for patients with epidural catheters. Elective surgery should be delayed accordingly. A low molecular weight heparin (LMWH) "bridging" (in fact "switching") should be avoided because of an increased bleeding risk. Six to 8 hours after the intervention rivaroxaban can be re-initiated or, in case of more extensive interventions or an increased bleeding risk, after 24-72 hours; if necessary this interval could by bridged with LMWH, e. g. if the thromboembolic risk is considered high. In case of emergency surgery with a rivaroxaban pause of less than 9 hours, one should be prepared for a bleeding management including the use of prothrombin concentrate (PCC). Coagulation tests have no value for predicting perioperative bleeding, in contrast to a standardised bleeding history. As an overall estimate, the PT (Quick) can be determined with a suitable reagent. Currently, rivaroxaban-specific measurements of anti Xa levels are available at few specialised centres only. Moderate to severe haemorrhages can usually be managed by temporary interruption of rivaroxaban in conjunction with local and general haemostatic measures. Life-threatening bleeding events require a specific haemostasis management including the administration of PCC; these events are rare and usually have a favourable prognosis, except for intracranial haemorrhages.

The efficacy and safety of the new oral, direct and selective thrombin inhibitor Ximelagatran and its active form Melagatran was analysed in patients undergoing total hip or knee replacement.Methro II, a randomised, double-blind controlled dose-finding study, involved 1876 patients. Melagatran (1, 1.5, 2.25 or 3 mg; twice daily; start: immediately before surgery) was given subcutaneously, followed by orally administered Ximelagatran (8, 12, 18 or 24 mg, twice daily, day after surgery) and compared to subcutaneously administered dalteparin (5000 IE, once daily). Methro III was a randomised, double blind controlled study involving 2788 patients. The fixed dose of 3 mg Melagatran was given (start: 4-12 hours postoperatively) followed by oral Ximelagatran (24 mg, twice daily, day after surgery) compared to subcutaneous enoxaparin (40 mg, once daily). In both studies, dalteparin or enoxaparin was applied at the evening before operation; the treatment lasted 8 to 11 days. A bilateral venography was performed at the last day of treatment.In the Methro II study, 1270 patients underwent total hip, 606 total knee replacement. In both groups the thromboembolism rate was reduced depending on the dose of Ximelagatran/Melagatran. Compared to dalteparin, it was significantly lower for the Ximelagatran/Melagatran group with the highest dose. In the Methro III study 1923 patients underwent a total hip, 865 a total knee replacement. The thromboembolism rate was 31% for the Ximelagatran/Melagatran group compared to 27% for the enoxaparin group. In both studies blood loss and transfusion requirement were in the same range as with low weight molecular heparins.A fixed subcutaneously given dose of Melagatran, followed by orally administered Ximelagatran is effective and well tolerated as prophylaxis against venous thromboembolism.

The main demands on a total hip replacement are to reduce pain or achieve painlessness and to recover or improve mobility and walking ability. Today more younger patients were operated replacing a destroyed hip joint: the reintegration in professional and sportive activities is a major part of the rehabilitation process. The postoperative management especially in physical therapy can be standardized inspite of the use of various models. Usually full weight bearing is accepted after 3 months. A review of consecutive treatment methods and professional and sportive rehabilitation measures are presented. Hip replacement leads to restrictions in activity in general. The evaluation, in relation to the different indemnifying, is differentiated.