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. 2020 Mar 9;4(3):366-376.
doi: 10.1002/rth2.12323. eCollection 2020 Mar.

What's new in VTE risk and prevention in orthopedic surgery

Susan R Kahn  1 , Sudeep Shivakumar  2
Affiliations

What's new in VTE risk and prevention in orthopedic surgery

Susan R Kahn et al. Res Pract Thromb Haemost. .

Abstract

A State of the Art lecture titled "What's New in VTE Risk and Prevention in Orthopedic Surgery" was presented at the ISTH congress in 2019. Patients undergoing orthopedic surgery have long been recognized to be at increased risk of venous thromboembolism (VTE) and were among the first patient groups to be studied in VTE prophylaxis trials. From the late 1950s to 2010s, prophylaxis trials in major orthopedic surgery tended to focus on venographic deep vein thrombosis and assessed thromboprophylaxis in all patients based on a population approach. In general, anticoagulants were favored over mechanical prophylaxis or aspirin, and longer-duration prophylaxis was favored over shorter durations. As discussed in this paper, more recently, orthopedic prophylaxis has started to become more nuanced and individualized. Modern trials are focusing on symptomatic VTE as outcomes; there has been a resurgence in interest in aspirin for prophylaxis, and there has been a slow move to studying ways to evaluate VTE risk in patients undergoing orthopedic surgery and recommending thromboprophylaxis to patients based on individual attributes, in whom risk stratification and weighing of benefit versus risk of thromboprophylaxis is becoming key. We also touch on VTE risk and guideline recommendations to prevent VTE in 2 other commonly encountered orthopedic populations: patients undergoing knee arthroscopy and those with distal leg fractures. Finally, we summarize relevant new data on this topic presented during the 2019 ISTH annual congress in Melbourne.

Keywords: aspirin; thromboprophylaxis; total hip arthoplasty; total knee arthroplasty; venous thromboembolism.

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Figures

Figure 1
Figure 1
Suggested risk stratification for hybrid DOAC/aspirin prophylaxis after total hip arthroplasty or total knee arthroplasty*. *Hybrid DOAC/aspirin prophylaxis = DOAC at prophylaxis dose (rivaroxaban 10 mg orally daily was used in EPCAT II trial) for 5 days, followed by aspirin 81 mg orally daily for 30 days (patients undergoing THA) or 9 days (patients undergoing TKA). If patient is on long‐term anticoagulation, usual long‐term anticoagulant should be reinitiated postoperatively per thrombosis service recommendations. DOAC, direct oral anticoagulant; GI, gastrointestinal; THA, total hip arthroplasty; TKA, total knee arthroplasty; VTE, venous thromboembolism
Figure 2
Figure 2
Shifting landscape in major orthopedic surgery prophylaxis. VTE, venous thromboembolism
See this image and copyright information in PMC

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