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Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physician Evidence-Based Clinical Practice Guidelines Online Only ArticlesPrevention of VTE in Orthopedic Surgery Patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines
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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.
References (135)
- et al.
Approach to outcome measurement in the prevention of thrombosis in surgical and medical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines
Chest
(2012) - et al.
Extended duration rivaroxaban versus short-term enoxaparin for the prevention of venous thromboembolism after total hip arthroplasty: a double-blind, randomised controlled trial
Lancet
(2008) - et al.
Prevention of venous thrombosis and pulmonary embolism in injured patients. A trial of anticoagulant prophylaxis with phenindione in middle-aged and elderly patients with fractured necks of femur
Lancet
(1959) - et al.
Apixaban versus enoxaparin for thromboprophylaxis after knee replacement (ADVANCE-2): a randomised double-blind trial
Lancet
(2010) - et al.
The efficacy and safety of apixaban, an oral, direct factor Xa inhibitor, as thromboprophylaxis in patients following total knee replacement
J Thromb Haemost
(2007) - et al.
BAY 59-7939: an oral, direct factor Xa inhibitor for the prevention of venous thromboembolism in patients after total knee replacement. A phase II dose-ranging study
J Thromb Haemost
(2005) - et al.
Rivaroxaban versus enoxaparin for thromboprophylaxis after total knee arthroplasty (RECORD4): a randomised trial
Lancet
(2009) - et al.
Dabigatran etexilate versus enoxaparin for prevention of venous thromboembolism after total hip replacement: a randomised, double-blind, non-inferiority trial
Lancet
(2007) - et al.
Oral dabigatran etexilate vs. subcutaneous enoxaparin for the prevention of venous thromboembolism after total knee replacement: the RE-MODEL randomized trial
J Thromb Haemost
(2007) - et al.
Prevention of postoperative venous thromboembolism in Japanese patients undergoing total hip or knee arthroplasty: two randomized, double-blind, placebo-controlled studies with three dosage regimens of enoxaparin
J Orthop Sci
(2008)
Low molecular weight heparin associated with spinal anaesthesia and gradual compression stockings in total hip replacement surgery
Br J Anaesth
A critical appraisal of bleeding events reported in venous thromboembolism prevention trials of patients undergoing hip and knee arthroplasty
J Thromb Haemost
Epidemiology of venous thromboembolism in Asian patients undergoing major orthopedic surgery without thromboprophylaxis. The SMART study
J Thromb Haemost
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
Chest
Extended-duration prophylaxis against venous thromboembolism after total hip or knee replacement: a meta-analysis of the randomised trials
Lancet
Efficacy and safety of prolonged thromboprophylaxis with a low molecular weight heparin (dalteparin) after total hip arthroplasty—the Danish Prolonged Prophylaxis (DaPP) Study
Thromb Res
Warfarin sodium in prevention of deep venous thrombosis and pulmonary embolism in patients with fractured neck of femur
Lancet
Why does prophylaxis with external pneumatic compression for deep vein thrombosis fail?
Am J Surg
Deep venous thrombosis prophylaxis in trauma: improved compliance with a novel miniaturized pneumatic compression device
J Vasc Surg
VenaFlow plus Lovenox vs VenaFlow plus aspirin for thromboembolic disease prophylaxis in total knee arthroplasty
J Arthroplasty
Postoperative fondaparinux versus preoperative enoxaparin for prevention of venous thromboembolism in elective hip-replacement surgery: a randomised double-blind comparison
Lancet
Postoperative fondaparinux versus postoperative enoxaparin for prevention of venous thromboembolism after elective hip-replacement surgery: a randomised double-blind trial
Lancet
Total hip replacement. American Academy of Orthopaedic Surgeons Web site
Reducing the risk of venous thromboembolism in patients admitted to hospital: summary of NICE guidance
BMJ
Major bleeding, mortality, and efficacy of fondaparinux in venous thromboembolism prevention trials
Circulation
Thrombosis prophylaxis. Dextran or warfarin-sodium? A controlled clinical study [in Norwegian]
Nord Med
Low risk of thromboembolic complications after fast-track hip and knee arthroplasty
Acta Orthop
The value of low dosage heparin for the prophylaxis of thromboembolism in patients with transcervical and intertrochanteric femoral fractures
Acta Orthop Scand
Aspirin-sulfinpyrazone in prophylaxis of deep venous thrombosis in total hip replacement
JAMA
Anticoagulant prophylaxis of venous thrombosis in patients with fractured neck of the femur; a controlled clinical trial using venous phlebography
Acta Chir Scand
Anticoagulant prophylaxis, thromboembolism and mortality in elderly patients with hip fractures. A controlled clinical trial
Acta Chir Scand
Frequency and timing of clinical venous thromboembolism after major joint surgery
J Bone Joint Surg Br
Apixaban versus enoxaparin for thromboprophylaxis after hip replacement
N Engl J Med
Apixaban or enoxaparin for thromboprophylaxis after knee replacement [published correction appears in N Engl J Med. 2009;36(18):1814]
N Engl J Med
A once-daily, oral, direct factor Xa inhibitor, rivaroxaban (BAY 59-7939), for thromboprophylaxis after total hip replacement
Circulation
Rivaroxaban versus enoxaparin for thromboprophylaxis after hip arthroplasty
N Engl J Med
Rivaroxaban versus enoxaparin for thromboprophylaxis after total knee arthroplasty
N Engl J Med
Oral dabigatran versus enoxaparin for thromboprophylaxis after primary total hip arthroplasty (RE-NOVATE II*). A randomised, double-blind, non-inferiority trial
Thromb Haemost
Oral thrombin inhibitor dabigatran etexilate vs North American enoxaparin regimen for prevention of venous thromboembolism after knee arthroplasty surgery
J Arthroplasty
Incidence and time course of thromboembolic outcomes following total hip or knee arthroplasty
Arch Intern Med
Duration of prophylaxis against venous thromboembolism with fondaparinux after hip fracture surgery: a multicenter, randomized, placebo-controlled, double-blind study
Arch Intern Med
Incidence of symptomatic venous thromboembolism after different elective or urgent surgical procedures
Thromb Haemost
Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial
Lancet
Thromboembolic prophylaxis for total knee arthroplasty in Asian patients: a randomised controlled trial
J Orthop Surg (Hong Kong)
Heparin/dihydroergotamine for venous thrombosis prophylaxis: comparison of low-dose heparin and low molecular weight heparin in hip surgery
Br J Surg
Prevention of deep vein thrombosis after major knee surgery—a randomized, double-blind trial comparing a low molecular weight heparin fragment (enoxaparin) to placebo
Thromb Haemost
Ardeparin (low-molecular-weight heparin) vs graduated compression stockings for the prevention of venous thromboembolism. A randomized trial in patients undergoing knee surgery
Arch Intern Med
Thromboprophylaxis by low-molecular-weight heparin in elective hip surgery. A placebo controlled study
J Bone Joint Surg Br
A randomized controlled trial of a low-molecular-weight heparin (enoxaparin) to prevent deep-vein thrombosis in patients undergoing elective hip surgery
N Engl J Med
A prospective randomized study on the use of nadroparin calcium in the prophylaxis of thromboembolism in Korean patients undergoing elective total hip replacement
Int Orthop
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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.
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