Chest
Volume 141, Issue 2, Supplement, February 2012, Pages e278S-e325S
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Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physician Evidence-Based Clinical Practice Guidelines Online Only Articles
Prevention of VTE in Orthopedic Surgery Patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

https://doi.org/10.1378/chest.11-2404Get rights and content

Background

VTE is a serious, but decreasing complication following major orthopedic surgery. This guideline focuses on optimal prophylaxis to reduce postoperative pulmonary embolism and DVT.

Methods

The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement.

Results

In patients undergoing major orthopedic surgery, we recommend the use of one of the following rather than no antithrombotic prophylaxis: low-molecular-weight heparin; fondaparinux; dabigatran, apixaban, rivaroxaban (total hip arthroplasty or total knee arthroplasty but not hip fracture surgery); low-dose unfractionated heparin; adjusted-dose vitamin K antagonist; aspirin (all Grade 1B); or an intermittent pneumatic compression device (IPCD) (Grade 1C) for a minimum of 10 to 14 days. We suggest the use of low-molecular-weight heparin in preference to the other agents we have recommended as alternatives (Grade 2C/2B), and in patients receiving pharmacologic prophylaxis, we suggest adding an IPCD during the hospital stay (Grade 2C). We suggest extending thromboprophylaxis for up to 35 days (Grade 2B). In patients at increased bleeding risk, we suggest an IPCD or no prophylaxis (Grade 2C). In patients who decline injections, we recommend using apixaban or dabigatran (all Grade 1B). We suggest against using inferior vena cava filter placement for primary prevention in patients with contraindications to both pharmacologic and mechanical thromboprophylaxis (Grade 2C). We recommend against Doppler (or duplex) ultrasonography screening before hospital discharge (Grade 1B). For patients with isolated lower-extremity injuries requiring leg immobilization, we suggest no thromboprophylaxis (Grade 2B). For patients undergoing knee arthroscopy without a history of VTE, we suggest no thromboprophylaxis (Grade 2B).

Conclusions

Optimal strategies for thromboprophylaxis after major orthopedic surgery include pharmacologic and mechanical approaches.

Section snippets

Summary of Recommendations

Note on Shaded Text: Throughout this guideline, shading is used within the summary of recommendations sections to indicate recommendations that are newly added or have been changed since the publication of Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Recommendations that remain unchanged are not shaded.

2.1.1. In patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA), we

Outcomes of Interest

All recommendations are based on the use of prophylaxis to reduce the patient-important outcomes of fatal and symptomatic pulmonary embolism (PE) and symptomatic DVT balanced against the hazard of an increase in symptomatic bleeding events. The design and reporting of clinical trials creates challenges in applying this approach. Studies have used varying definitions of important bleeding, and it was sometimes difficult to extract data regarding patient-important bleeding outcomes (those that

LMWH vs No Prophylaxis—Initial and Extended-Period Prophylaxis

LMWH has become the thromboprophylaxis agent against which newer drugs are compared. Several studies published in the mid-1980s, during the 1990s, and as recently as 2008 have investigated LMWH compared with no prophylaxis in > 2,000 patients to test the hypothesis that LMWH decreases the incidence of VTE after arthroplasty31, 32, 33, 34, 35, 36, 37, 38, 39, 47, 48 and HFS.49, 50 Our analysis included all studies of LMWH vs no prophylaxis whether GCS were used in both groups because this would

Isolated Lower-Leg Injuries Distal to the Knee

Lower-leg injuries are a heterogeneous mix and include fractures below the knee, tendon ruptures, and cartilage injuries of the knee and ankle. There is less evidence about the incidence of patient-important VTE events associated with these injuries compared with major orthopedic surgery, but the risk of DVT increases with proximity of the fracture to the knee.126

A Cochrane systematic review analyzed data from six randomized trials involving close to 1,500 patients who required lower-leg

Knee Arthroscopy

Knee arthroscopy and arthroscopic-assisted knee surgery is performed frequently and most often as outpatient procedures in a relatively young patient population. A systematic review129 that included four RCTs examined the use of LMWH vs no thromboprophylaxis after arthroscopic knee surgery in 527 patients.130, 131, 132, 133 The knee surgeries included were anterior cruciate ligament reconstruction, meniscectomies, and other diagnostic and therapeutic arthroscopies. No trial was blinded to

Direction of Future Studies

Large, practical, RCTs are needed to further study thromboprophylaxis after orthopedic surgeries. Those trials should avoid screening for asymptomatic VTE and ensure that symptomatic VTE is recorded up to 3 months after surgery, regardless of duration of intervention. To ensure sufficient methodologic rigor, independent adjudication of outcomes not only for VTE but also for major bleeding events are essential, as is ensuring allocation concealment through central randomization, blinding of data

Conclusions

VTE is an important complication after major orthopedic surgery, and numerous approaches to its prevention have been evaluated. This article reviews the effectiveness and safety of these approaches and provides guidelines using methods that differ somewhat from prior versions. First, recommendations have been based on patient-important outcomes that include symptomatic PE and DVT, bleeding, and death, whereas asymptomatic venous thrombosis identified by screening tests are not used as a basis

Acknowledgments

Author contributions: As Topic Editor, Dr Falck-Ytter oversaw the development of this article, including the data analysis and subsequent development of the recommendations contained herein.

Dr Falck-Ytter: served as Topic Editor.

Dr Francis: served as Deputy Editor.

Dr Johanson: served as a panelist.

Dr Curley: served as frontline clinician.

Dr Dahl: served as a panelist.

Dr Schulman: served as a panelist.

Dr Ortel: served as a panelist.

Dr Pauker: served as a panelist.

Dr Colwell: served as a panelist.

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    Funding/Support: The Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines received support from the National Heart, Lung, and Blood Institute [R13 HL104758] and Bayer Schering Pharma AG. Support in the form of educational grants was also provided by Bristol-Myers Squibb; Pfizer, Inc; Canyon Pharmaceuticals; and sanofi-aventis US.

    Disclaimer: American College of Chest Physician guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://chestjournal.chestpubs.org/content/141/2_suppl/1S.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

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