This 2018 narrative review summarizes VTE risk, prophylaxis options, and guideline recommendations across major orthopaedic procedures. It covers mechanical and pharmacological methods, with specific guidance for total hip and knee replacement, hip fracture surgery, knee arthroscopy, spine surgery, and upper extremity surgery. The central question: which prophylaxis agent and duration are appropriate for each orthopaedic scenario?
Every orthopaedic patient undergoing hip or knee arthroplasty or hip fracture fixation sits in the highest VTE risk category — higher than general surgery, higher than most medical patients. Without prophylaxis, nearly half will develop DVT.
When choosing an agent, default to LMWH: it outperforms warfarin, UFH, and aspirin for DVT prevention, carries a 13-fold lower HIT risk than UFH, and is the only agent recommended across all three high-risk procedures (total hip replacement, total knee replacement, and hip fracture surgery). Start it 12 hours before or after surgery. Never within 4 hours.
When a patient on a novel oral anticoagulant asks about prophylaxis after hip fracture repair, remember: rivaroxaban, dabigatran, and apixaban are not recommended for hip fracture surgery. LMWH or fondaparinux is the correct choice.
For knee arthroscopy in a patient with no prior VTE history, ACCP says no routine prophylaxis. But a patient with prior VTE, malignancy, or two or more risk factors deserves individualized consideration.
This 2018 narrative review summarizes VTE risk, prophylaxis options, and guideline recommendations across major orthopaedic procedures. It covers mechanical and pharmacological methods, with specific guidance for total hip and knee replacement, hip fracture surgery, knee arthroscopy, spine surgery, and upper extremity surgery. The central question: which prophylaxis agent and duration are appropriate for each orthopaedic scenario?
Every orthopaedic patient undergoing hip or knee arthroplasty or hip fracture fixation sits in the highest VTE risk category — higher than general surgery, higher than most medical patients. Without prophylaxis, nearly half will develop DVT.
When choosing an agent, default to LMWH: it outperforms warfarin, UFH, and aspirin for DVT prevention, carries a 13-fold lower HIT risk than UFH, and is the only agent recommended across all three high-risk procedures (total hip replacement, total knee replacement, and hip fracture surgery). Start it 12 hours before or after surgery. Never within 4 hours.
When a patient on a novel oral anticoagulant asks about prophylaxis after hip fracture repair, remember: rivaroxaban, dabigatran, and apixaban are not recommended for hip fracture surgery. LMWH or fondaparinux is the correct choice.
For knee arthroscopy in a patient with no prior VTE history, ACCP says no routine prophylaxis. But a patient with prior VTE, malignancy, or two or more risk factors deserves individualized consideration.