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.
BACKGROUND
VTE is a serious, but decreasing complication following major orthopedic surgery. This guideline focuses on optimal prophylaxis to reduce postoperative pulmonary embolism and DVT.


METHODS
The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement.


RESULTS
In patients undergoing major orthopedic surgery, we recommend the use of one of the following rather than no antithrombotic prophylaxis: low-molecular-weight heparin; fondaparinux; dabigatran, apixaban, rivaroxaban (total hip arthroplasty or total knee arthroplasty but not hip fracture surgery); low-dose unfractionated heparin; adjusted-dose vitamin K antagonist; aspirin (all Grade 1B); or an intermittent pneumatic compression device (IPCD) (Grade 1C) for a minimum of 10 to 14 days. We suggest the use of low-molecular-weight heparin in preference to the other agents we have recommended as alternatives (Grade 2C/2B), and in patients receiving pharmacologic prophylaxis, we suggest adding an IPCD during the hospital stay (Grade 2C). We suggest extending thromboprophylaxis for up to 35 days (Grade 2B). In patients at increased bleeding risk, we suggest an IPCD or no prophylaxis (Grade 2C). In patients who decline injections, we recommend using apixaban or dabigatran (all Grade 1B). We suggest against using inferior vena cava filter placement for primary prevention in patients with contraindications to both pharmacologic and mechanical thromboprophylaxis (Grade 2C). We recommend against Doppler (or duplex) ultrasonography screening before hospital discharge (Grade 1B). For patients with isolated lower-extremity injuries requiring leg immobilization, we suggest no thromboprophylaxis (Grade 2B). For patients undergoing knee arthroscopy without a history of VTE, we suggest no thromboprophylaxis (Grade 2B).


CONCLUSIONS
Optimal strategies for thromboprophylaxis after major orthopedic surgery include pharmacologic and mechanical approaches.
Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, OH. Electronic address: Yngve.Falck-Ytter@case.edu.
Yngve
Y
Falck-Ytter
Hematology/Oncology Unit, University of Rochester Medical Center, Rochester, NY.
Charles W
CW
Francis
Department of Orthopaedic Surgery, Drexel University College of Medicine, Philadelphia, PA.
Norman A
NA
Johanson
Division of Hospital Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH.
Catherine
C
Curley
Innlandet Hospitals, Brumunddal, Norway; Thrombosis Research Institute, Chelsea, London, England.
Ola E
OE
Dahl
Department of Medicine, Division of Hematology and Thromboembolism, McMaster University, Hamilton, ON, Canada.
Sam
S
Schulman
Hemostasis and Thrombosis Center, Duke University Health System, Durham, NC.
Thomas L
TL
Ortel
Tufts Medical Center, Boston, MA.
Stephen G
SG
Pauker
Shiley Center for Orthopaedic Research and Education at Scripps Clinic, La Jolla, CA.
Clifford W
CW
Colwell
D003131:Combined Modality Therapy; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D019317:Evidence-Based Medicine; D005343:Fibrinolytic Agents / Q000009:adverse effects / Q000493:pharmacokinetics / Q000627:therapeutic use*; D006470:Hemorrhage / Q000097:blood / Q000139:chemically induced / Q000517:prevention & control; D006801:Humans; D048228:Intermittent Pneumatic Compression Devices; D019637:Orthopedic Procedures; D011183:Postoperative Complications / Q000097:blood / Q000188:drug therapy* / Q000517:prevention & control*; D011655:Pulmonary Embolism / Q000097:blood / Q000188:drug therapy / Q000517:prevention & control; D012307:Risk Factors; D012955:Societies, Medical; D054556:Venous Thromboembolism / Q000097:blood / Q000188:drug therapy* / Q000517:prevention & control*
D005343:Fibrinolytic Agents