Journal of Postgraduate Medicine, Education and Research

Register      Login

VOLUME 53 , ISSUE 4 ( October-December, 2019 ) > List of Articles


Routine Chemoprophylaxis for Venous Thromboembolism in Orthopedic Patients: Is it Justified?

Prasoon Kumar, Rohit Kansal

Keywords : Acetabulum fractures, Arthroplasty, Chemoprophylaxis, Deep vein thrombosis, Long-bone fractures, Pelvic fractures, Pulmonary embolism, Venous thromboembolism

Citation Information : Kumar P, Kansal R. Routine Chemoprophylaxis for Venous Thromboembolism in Orthopedic Patients: Is it Justified?. J Postgrad Med Edu Res 2019; 53 (4):152-157.

DOI: 10.5005/jp-journals-10028-1334

License: CC BY-NC 4.0

Published Online: 01-06-2018

Copyright Statement:  Copyright © 2019; The Author(s).


Introduction: Orthopedic patients require prolonged immobilization and undergo major surgical procedures which make them susceptible to venous thromboembolism (VTE). The role of chemoprophylaxis to prevent VTE is still debated, with many surgeons using it routinely, while certain centers use it sporadically. The present review assesses the evidence in literature regarding the VTE chemoprophylaxis in different subsets of orthopedic patients with specific focus on arthroplasty, pelvic trauma, and long-bone fractures. Materials and methods: A PubMed search to look for current usage of routine chemoprophylaxis in hip/knee arthroplasties and postoperative cases of pelvic-acetabular, hip, and tibia fractures yielded 2,216 hits. Based on the relevant articles, the evidence in literature was studied to determine the role of chemoprophylaxis. Results: The incidence of VTE in orthopedics patients is well documented with several studies, both Indian and Western quoting rates of up to 72%. There are no guidelines from any Indian orthopedics body or society, and most of the surgeons rely on the recommendations from the American Academy of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP). These guidelines are based on the review of the literature and recommend routine chemoprophylaxis to prevent VTE in hip/knee arthroplasties and hip fractures. Low molecular weight heparin, apixaban, rivaroxaban, and fondaparinux are potential agents. Oral low-dose aspirin is also effective in arthroplasty patients, while its efficacy may not be at par with the other agents in trauma cases; the evidence is however still not clear. There is no similar role of routine chemoprophylaxis in fractures distal to the knee; as the thrombi formed are distal, they do not often embolize to the lungs and are rarely clinically significant. Conclusion: Patients undergoing hip and knee arthroplasties or surgeries for pelvic-acetabular and hip fractures require routine VTE chemoprophylaxis. LMWH or newer agents like apixaban or fondaparinux are effective in decreasing the incidence of clinical VTE and could be prescribed for a period as long as 6–8 weeks postoperatively.

  1. Sen RK, Kumar A, Tripathy SK, et al. Risk of postoperative venous thromboembolism in Indian patients sustaining pelvi-acetabular injury. Int Orthop 2011;35(7):1057–1063. DOI: 10.1007/s00264-010-1093-6.
  2. Agarwal S, Bhagwat AS, Modhe J. Deep vein thrombosis in Indian patients undergoing major lower limb surgery: Distribution of thrombi and its significance. Indian J Surg 2003;65:159–162. DOI: 10.1007/s13193-016-0538-9.
  3. Dhillon KS, Askander A, Doraisamy S. Postoperative deep vein thrombosis in Asian patients is not a rarity. J Bone Joint Surg Br 1996;78:427–430. DOI: 10.1302/0301-620X.78B3.0780427.
  4. Chan YK, Chiu KY. The incidence of DVT in elderly Chinese suffering hip fracture is low. J Orth Surg 2004;12(2):178–183. DOI: 10.1177/230949900401200208.
  5. Nagi ON, Dhillon MS, Katariya S, et al. Deep vein thrombosis after major surgery-evaluation by compression ultrasonography. Indian J Orthop 1999;33:200–203.
  6. Sen RK, Tripathy SK, Singh AK. Is routine thromboprophylaxis justified among Indian patients sustaining major orthopedic trauma? A systematic review. Indian J Orthop 2011;45(3):197–207. DOI: 10.4103/0019-5413.80037.
  7. Bagaria V, Modi N, Panghate A, et al. Incidence and risk factors for development of venous thromboembolism in Indian patients undergoing major orthopaedic surgery: Results of a prospective study. Postgrad Med J 2006;82:136–139. DOI: 10.1136/pgmj.2005. 034512.
  8. Mavalankar AP, Majmundar D, Sudha R. Routine chemoprophylaxis for DVT in Indian patients. Indian J Orthop 2007;41:188–191. DOI: 10.4103/0019-5413.33680.
  9. Lieberman JR, Pensak MJ. Prevention of venous thromboembolic disease after total hip and knee arthroplasty. J Bone Joint Surg Am 2013;95(19):1801–1811. DOI: 10.2106/JBJS.L.01328.
  10. Mont MA, Jacobs JJ. AAOS clinical practice guideline: preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Am Acad Orthop Surg 2011;19(12):777–778. DOI: 10.5435/00124635-201112000-00008.
  11. Johanson NA, Lachiewicz PF, Lieberman JR, et al. American academy of orthopaedic surgeons clinical practice guideline on prevention of symptomatic pulmonary embolism in patients undergoing total hip or knee arthroplasty. J Bone Joint Surg Am 2009;91(7):1756–1757. DOI: 10.2106/JBJS.I.00511.
  12. Eisenberg MJ, Richard PR, Libersan D, et al. Safety of short-term discontinuation of antiplatelet therapy in patients with drug-eluting stents. Circulation 2009;119(12):1634–1642. DOI: 10.1161/CIRCULATIONAHA.108.813667.
  13. Geerts WH, Bergqvist D, Pineo GF, et al. American College of Chest Physicians. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008;133(6 Suppl):381S–453S. DOI: 10.1378/chest.08-0656.
  14. Falck-Ytter Y, Francis CW, Johanson NA, et al. American College of Chest Physicians. 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. Chest 2012;141(2 Suppl):e278S–e325S. DOI: 10.1378/chest.11-2404.
  15. Pulmonary Embolism Prevention (PEP) Trial Col laborative Group. Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial. Lancet 2000;355(9212):1295–1302. DOI: 10.1016/S0140-6736(00)02110-3.
  16. Miller RS, Weatherford DA, Stein D, et al. Antithrombin III and trauma patients: factors that determine low levels. J Trauma Inj Infect Crit Care 1994;37:442–445. DOI: 10.1097/00005373-199409000-00019.
  17. Montgomery KD, Geerts WH, Code KI. Thromboembolic complications in patients with Pelvic trauma. Clin Orthop 1996;329:68–87. DOI: 10.1097/00003086-199608000-00010.
  18. Selby R, Geerts W, Ofsosu FA, et al. Hypercoagulability after trauma: hemostatic charges and relationship to venous thromboembolism. Thromb Res 2009;124(3):281–287. DOI: 10.1016/j.thromres.2008.10.002.
  19. Tubiana R, Duparc J. Prevention of Thromboembolic complications in orthopaedic and accidental injuries. J Bone Joint Surg (Br) 1961;43:7–51. DOI: 10.1302/0301-620X.43B1.7.
  20. Stannard JP, Riley RS, McClenney MD, et al. Mechanical Prophylaxis against Deep-Vein Thrombosis After Pelvic and Acetabular Fractures. J Bone Joint Surg (Am) 2001;83:1047–1051. DOI: 10.2106/00004623-200107000-00010.
  21. Steele N, Dodenhoff RM, Ward AJ, et al. Thromboprophylaxis in pelvic and acetabular trauma surgery. The role of early treatment with low-molecular-weight heparin. J Bone Joint Surg Br 2005;87:209–212. DOI: 10.1302/0301-620X.87B2.14447.
  22. Fishmann AJ, Greeno RA, Brooks LR, et al. Prevention of deep vein thrombosis and pulmonary embolism in acetabular and pelvic fracture surgery. Clin Orthop Relat Res 1994;305:133–137. DOI: 10.1097/00003086-199408000-00017.
  23. Velmahos GC. Posttraumatic thromboprophylaxis revisited: An argument against the current method of DVT and PE prophylaxis after injury. World J Surg 2006;30:483–487. DOI: 10.1007/s00268-005-0427-9.
  24. Dennis J, Menawat WS, Von Thron J, et al. Efficacy of deep venous thrombosis prophylaxis in trauma patients and identification of high-risk groups. J Trauma 1993;35:132–138. DOI: 10.1097/00005373-199307000-00021.
  25. Burns GA, Cohn SM, Frumento RJ, et al. Prospective ultrasound evaluation of venous thrombosis in high risk trauma patients. J Trauma 1993;35:405–408. DOI: 10.1097/00005373-199309000-00012.
  26. Comerota AJ, Katz ML, White JV. Why does prophylaxis with external pneumatic compression for deep vein thrombosis fail? Am J Surg 1992;164:265–268. DOI: 10.1016/S0002-9610(05)81083-9.
  27. Ruiz AJ, Hill SL, Berry RE. Heparin, Deep Venous Thrombosis and trauma patients. Am J Surg 1991;162:159–162. DOI: 10.1016/0002-9610(91)90180-L.
  28. Sen RK, Kumar A, Tripathy S, et al. Risk factors of venous thromboembolism in Indian patients with pelvic-acetabular trauma. J Orthop Surg (Hong Kong) 2011 Apr;19(1):18–24. DOI: 10.1177/230949901101900105.
  29. Geerts WH, Code KI, Jay RM, et al. A prospective study of venous thromboembolism after major trauma. N Engl J Med 1994;331: 1601–1606. DOI: 10.1056/NEJM199412153312401.
  30. Slobogean GP, Lefaivre KA, Nicolaou S, et al. A systematic review of thromboprophylaxis for pelvic and acetabular fractures. J Orthop Trauma 2009;23(5):379–384. DOI: 10.1097/BOT.0b013e3181a5369c.
  31. El-Daly I, Reidy J, Culpan P, et al. Thromboprophylaxis in patients with pelvic and acetabular fractures: a short review and recommendations. Injury 2013;44(12):1710–1720. DOI: 10.1016/j.injury.2013.04.030.
  32. Sharma OP, Oswanski MF, Joseph RJ, et al. Venous thromboembolism in trauma patients. Am Surg 2007;73(11):1173–1180.
  33. Rasmussen MS, Jørgensen LN, Wille-Jørgensen P. Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery. Cochrane Database Syst Rev 2009;(1):CD004318. DOI: 10.1002/14651858.CD004318.pub2.
  34. de Alvarenga YR. New anticoagulants for venous thromboembolism prophylaxis in major orthopedic surgeries. A systematic review of randomized controlled trials. J Vasc Bras 2012;11:1–2. DOI: 10.1590/S1677-54492012000100001.
  35. Karthikeyan G, Eikelboom JW, Turpie AG, et al. Does acetyl salicylic acid (ASA) have a role in the prevention of venous thromboembolism? Br J Haematol 2009;146(2):142–149. DOI: 10.1111/j.1365-2141.2009.07734.x.
  36. Monzon DG, Iserson KV, Cid A, et al. Oral thromboprophylaxis in pelvic trauma: a standardized protocol. J Emerg Med 2012;43(4):612–617. DOI: 10.1016/j.jemermed.2011.09.006.
  37. Flevas DA, Megaloikonomos PD, Dimopoulos L, et al. Thromboembolism prophylaxis in orthopaedics: an update. EFORT Open Rev 2018 Apr 27;3(4):136–148. DOI: 10.1302/2058-5241.3. 170018.
  38. Scottish Intercollegiate Guidelines Network (SIGN). Prevention and management of venous thromboembolism. SIGN publication no. 122. Edinburgh: SIGN; 2010.
  39. Marsland D, Mears SC, Kates SL. Venous thromboembolic prophylaxis for hip fractures. Osteoporos Int 2010;21(Suppl 4):S593–S604. DOI: 10.1007/s00198-010-1403-2.
  40. Ktistakis I, Giannoudis V, Giannoudis PV. Anticoagulation therapy and proximal femoral fracture treatment: an update. EFORT Open Rev 2017;1:310–315. DOI: 10.1302/2058-5241.1.160034.
  41. Selby R, Geerts WH, Crowther MA, et al. A prospective cohort study of the epidemiology of symptomatic venous thromboembolism (VTE) after isolated leg fractures distal to the knee without thromboprophylaxis. Blood 2004;104:143A. DOI: 10.1182/blood-2003-11-4085.
  42. Cohen AT, Balaratnam S, Fassiadis N. Are isolated distal deep-vein thromboses clinically significant? Therapy 2008;5:151–157. DOI: 10.2217/14750708.5.2.151.
  43. Patterson JT, Morshed S. Chemoprophylaxis for Venous Thromboembolism in Operative Treatment of Fractures of the Tibia and Distal Bones: A Systematic Review and Meta-analysis. J Orthop Trauma 2017;31(9):453–460. DOI: 10.1097/BOT.0000000000000873.
  44. Sagi HC, Ahn J, Ciesla D, et al. Venous thromboembolism prophylaxis 390 in orthopaedic trauma patients: a survey of OTA member practice patterns and OTA expert panel recommendations. J Orthop Trauma 2015;29:e355–e362. DOI: 10.1097/BOT.0000000000000387.
  45. Cushman M. Epidemiology and risk factors for venous thrombosis. Semin Hematol 2007;44(2):62–69. DOI: 10.1053/j.seminhematol.2007.02.004.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.