SLR - July 2012 - Nicole Cullen
Reference: Falck-Ytter Y, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S, Ortel TL, Pauker SG, Colwell Jr. CW. 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:e278S-e325S
Scientific Literature Review
Reviewed by: Nicole Cullen, DPM
Residency Program: Mercy Hospital - Coon Rapids, Minnesota
Podiatric Relevance:
Recently there has been considerable debate concerning venous thromboembolism (VTE) prophylaxis for lower extremity surgical procedures or injuries requiring immobilization. As a result, there has been a need for an evidence-based consensus to determine the necessity for prophylaxis in these patients. The purpose of this review was to evaluate the need for prophylaxis in orthopaedic surgical and trauma patients, including those with isolated lower extremity injuries.
Methods:
A systematic literature review utilizing Medline, the Cochrane Library, meeting abstracts, conference proceedings and reference lists of studies was performed. Data were also pooled using a random-effects model for three or more studies. VTE risk and timing of occurrence were analyzed in patients undergoing total hip arthroplasty, total knee arthroplasty, hip fracture repair, knee arthroscopy and those patients with isolated lower extremity injuries. Comparisons were also made between low molecular weight heparin, fondaparinux, apixaban, dabigatran, rivaroxaban, adjusted-dose vitamin K antagonist, aspirin and low-dose unfractionated heparin.
Results:
Baseline risk for symptomatic VTE was determined to be 4.3 percent in the 35 days following the previously discussed orthopaedic procedures or injuries. Major bleeding risk was determined to be 1.5 percent for those same patients. In patients with isolated lower extremity injuries, the risk of developing a pulmonary embolism (PE) was found to be 0.003 percent, compared to a one percent risk of PE in major orthopaedic surgery patients. Major orthopaedic surgery includes total hip arthroplasty, total knee arthroplasty, or hip fracture repair. No benefit was found for prophylaxis in those patients with isolated lower extremity injuries.
Conclusions:
The reviewers made several recommendations for those patients who are not at high risk for developing a deep vein thrombosis (DVT) based on their thorough review of the literature. Patients undergoing major orthopaedic surgery who are low risk for developing a DVT and do not have increased bleeding risk should be prophylaxed with a pharmacological agent, preferably low molecular weight heparin, for 35 days. Patients with major bleeding risks should be treated with pneumatic compression devices or no prophylaxis at all. Patients with isolated lower-extremity injuries requiring immobilization are not recommended to receive prophylaxis. The literature failed to demonstrate any increased benefit to prophylaxing these patients.