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Prevention of venous thromboembolism in the orthopedic surgery patient

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ABSTRACT

Patients undergoing major orthopedic surgery—hip or knee arthroplasty, or hip fracture repair—are in the highest risk category for venous thromboembolism (VTE) solely on the basis of the orthopedic procedure itself. Despite this, nearly half of patients undergoing these procedures do not receive appropriate prophylaxis against VTE, often due to a disproportionate fear of bleeding complications in this population. Guidelines from the American College of Chest Physicians (ACCP) provide evidence-based recommendations for many aspects of VTE risk reduction in the setting of orthopedic surgery, as detailed in this review. The ACCP recommends the use of either low-molecular-weight heparin (LMWH), fondaparinux, or adjusted-dose warfarin as preferred VTE prophylaxis in patients undergoing either hip or knee arthroplasty. Fondaparinux is the preferred recommendation for patients undergoing hip fracture repair, followed by LMWH, unfractionated heparin, and adjusted-dose warfarin as alternative options. Extended-duration prophylaxis (for 4 to 5 weeks) is now recommended for patients undergoing hip arthroplasty or hip fracture repair. Patients undergoing knee arthroscopy do not require routine pharmacologic VTE prophylaxis.


 

References

Nearly half of orthopedic surgery patients do not receive appropriate prophylaxis for venous thromboembolism (VTE), as defined by American College of Chest Physicians (ACCP) consensus guidelines, according to a recent analysis of a nationwide database of hospital admissions. 1 Even in teaching hospitals, compliance with consensus guidelines for thromboprophylaxis is suboptimal. In a study of adherence to the ACCP guidelines for VTE prevention among 1,907 surgical patients at 10 teaching hospitals, only 45.2% of hip fracture patients received optimal VTE prophylaxis. 2 Rates of optimal prophylaxis were higher among patients undergoing hip arthroplasty and knee arthroplasty—84.3% and 75.9%, respectively—but were still in need of improvement. 2

GROWING INTEREST IN POSTOPERATIVE VTE PROPHYLAXIS AS A QUALITY INDICATOR

As noted in the introductory article in this supplement, the Joint Commission on Accreditation of Healthcare Organizations has taken notice of these shortcomings and has proposed national consensus standards for VTE prevention and treatment. 3 Among its proposed standards are two related to risk assessment and prophylaxis: whether risk assessment/prophylaxis is ordered within 24 hours of hospital admission and within 24 hours of transfer to the intensive care unit.

Other quality-monitoring initiatives are focused specifically on VTE in the surgical population. The Surgical Care Improvement Project (SCIP) has approved two quality measures with respect to VTE prevention: (1) the proportion of surgical patients for whom recommended VTE prophylaxis is ordered, and (2) the proportion of patients who receive appropriate VTE prophylaxis (based on ACCP guideline recommendations) within 24 hours before or after surgery. 4

In the future, two other VTE-related quality measures from SCIP may be implemented by the Centers for Medicare and Medicaid Services: (1) how often intra- or postoperative pulmonary embolism (PE) is diagnosed during the index hospitalization and within 30 days of surgery, and (2) how often intra- or postoperative deep vein thrombosis (DVT) is diagnosed during the index hospitalization and within 30 days of surgery. 5

VTE RISK IN ORTHOPEDIC SURGERY

Surgical patients can be stratified into four VTE risk levels—low, moderate, high, and highest—based on age, surgery type, surgery duration, duration of immobilization, and other risk factors. 6 For patients undergoing orthopedic surgery, these levels may be defined according to the following patient and surgical characteristics:

  • Low risk —surgery duration of less than 30 minutes, age less than 40 years, repair of small fractures
  • Moderate risk —age of 40 to 60 years, arthroscopy or repair of lower leg fractures, postoperative plaster cast
  • High risk —age greater than 60 years, or age 40 to 60 years with additional VTE risk factors, or immobilization for greater than 4 days
  • Highest risk —hip or knee arthroplasty, hip fracture repair, repair of open lower leg fractures, major trauma or spinal cord injury, or multiple risk factors for VTE (age > 40 years, prior VTE, cancer, or hypercoagulable state).

For patients in the low-risk category, no specific prophylaxis is indicated beyond early and aggressive ambulation. 6 For those in all other risk categories, prophylaxis with pharmacologic anticoagulant agents and/or mechanical devices is indicated, as reviewed below.

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