Justin Kleiner, Marc Swiontkowski, Paul Tornetta III.
Response/Recommendation: Surgical procedures in the upper extremity and distal to the ankle can be considered non-major. The risk of venous thromboembolism (VTE) increases in the lower limb from the distal leg (or ankle) to the pelvis, with higher risk associated with more proximal surgeries. In addition to location of surgery, length of surgery and expected post-operative mobility must be considered.
Strength of Recommendation: Moderate.
Rationale: Venous thromboembolism (VTE) is a significant source of morbidity and mortality following orthopedic surgery1,2. The risk of VTE following orthopaedic surgery varies significantly based on many patients and surgical factors3–7. It is important to stratify this risk in order to develop an appropriate anticoagulation plan post-operatively8–10.
Most lower extremity surgery is associated with significant VTE risk and should be considered major. n patients with isolated tibia or distal lower leg fracture, meta-analysis showed that low-molecular-weight heparin reduces risk of overall deep venous thrombosis (DVT) (relative risk 0.7)11. However, anticoagulation was not shown to reduce rate of clinically important VTE, defined as proximal or symptomatic DVT11. In elective arthroplasty patients, symptomatic VTE occurs in 2-3%, and asymptomatic DVT has been reported in up to 40% of patients without anticoagulant thromboprophylaxis12,13. Further, the Caprini score was introduced to predict the risk of VTE after orthopaedic surgery. Notably, a score > 10 predicts increased risk, with 5 points for lower extremity fracture, elective arthroplasty, or polytrauma14. This risk is reflected in current practice, as survey data indicates that 76% of orthopaedic surgeons recommended chemical DVT prophylaxis in foot and ankle fractures15. This increases to 86% for tibia fractures, and >95% for all other lower extremity fractures15. Agency for Healthcare Research and Quality (AHRQ) guidelines for VTE prophylaxis define major orthopaedic surgery as total hip arthroplasty, total knee arthroplasty, and hip fracture surgery, and recommend chemical prophylaxis for these operations16.
Orthopaedic procedures in the upper extremity, lower extremity arthroscopy, and surgery distal to the ankle in patients with isolated injuries have lower VTE risk and can be considered non-major. In a large database study, risk of DVT in patients with upper extremity surgery was 0.2%17. In current clinical practice, orthopaedic surgeons recommend chemical anticoagulation in 38% of isolated upper extremity injuries, less frequently than in lower extremity surgeries15. Patients undergoing foot and ankle surgery also have rates of VTE less than 1%18. However, this risk is higher in patients undergoing foot and ankle surgery for orthopaedic trauma – especially in cases where chemical prophylaxis is not used (up to 36%)18. Despite the higher overall occurrence of VTE in foot and ankle trauma patients, the actual rate of proximal DVT was significantly lower – ranging between 0.9-6.4%. In a meta-analysis of patients undergoing knee arthroscopy, only 10 out of 921 had symptomatic DVT without anticoagulation19. Reflecting this data, the American College of Chest Physicians guidelines recommend no chemical VTE prophylaxis after knee arthroscopy, due to low rate of DVT and equivalent risk of bleeding complications20.
While anatomic location of surgery is an important predictor of post-operative DVT, additional factors must be considered when defining major surgery. Notably, length of surgery and expected patient mobility post-operatively must be considered when defining VTE risk9,21–23.
1. Drescher FS, Sirovich BE, Lee A, Morrison DH, Chiang WH, Larson RJ. Aspirin versus anticoagulation for prevention of venous thromboembolism major lower extremity orthopedic surgery: a systematic review and meta-analysis. J Hosp Med. 2014;9(9):579-585. doi:10.1002/jhm.2224
2. Fisher W. Managing hip fracture and lower limb surgery in the emergency setting: Potential role of non-vitamin K antagonist oral anticoagulants. J Trauma Acute Care Surg. 2017;82(6):1112-1121. doi:10.1097/TA.0000000000001453
3. Morais QCD, Santos MS. Multi-Criteria Model for Evaluating Drugs to Prevent Deep Venous Thrombosis Associated With Orthopedic Surgery: A Hospital-Based Case Study. Value Health Reg Issues. 2020;23:105-111. doi:10.1016/j.vhri.2020.08.002
4. Anderson DR, Morgano GP, Bennett C, et al. American Society of Hematology 2019 guidelines for management of venous thromboembolism: prevention of venous thromboembolism in surgical hospitalized patients. Blood Adv. 2019;3(23):3898-3944. doi:10.1182/bloodadvances.2019000975
5. Pan Y, Mei J, Wang L, et al. Investigation of the Incidence of Perioperative Pulmonary Embolism in Patients with Below-Knee Deep Vein Thrombosis after Lower Extremity Fracture and Evaluation of Retrievable Inferior Vena Cava Filter Deployment in These Patients. Ann Vasc Surg. 2019;60:45-51. doi:10.1016/j.avsg.2019.02.027
6. Villarreal JV, Shibuya N, Jupiter DC. Thromboprophylaxis and Bleeding Complications in Orthopedic and Trauma Patients: A Systematic Review. J Foot Ankle Surg. 2021;60(5):1014-1022. doi:10.1053/j.jfas.2021.03.010
7. Wæver D, Lewis D, Saksø H, Borris LC, Tarrant S, Thorninger R. The Effectiveness and Safety of Direct Oral Anticoagulants Following Lower Limb Fracture Surgery: A Systematic Review and Meta-analysis. J Orthop Trauma. 2021;35(4):217-224. doi:10.1097/BOT.0000000000001962
8. Haac BE, O’Hara NN, Manson TT, et al. Aspirin versus low-molecular-weight heparin for venous thromboembolism prophylaxis in orthopaedic trauma patients: A patient-centered randomized controlled trial. PLoS One. 2020;15(8):e0235628. doi:10.1371/journal.pone.0235628
9. Haac BE, O’Hara NN, Mullins CD, et al. Patient preferences for venous thromboembolism prophylaxis after injury: a discrete choice experiment. BMJ Open. 2017;7(8):e016676. doi:10.1136/bmjopen-2017-016676
10. Nederpelt CJ, Breen KA, El Hechi MW, et al. Direct Oral Anticoagulants Are a Potential Alternative to Low-Molecular-Weight Heparin for Thromboprophylaxis in Trauma Patients Sustaining Lower Extremity Fractures. J Surg Res. 2021;258:324-331. doi:10.1016/j.jss.2020.10.009
11. 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
12. Farfan M, Bautista M, Bonilla G, Rojas J, Llinás A, Navas J. Worldwide adherence to ACCP guidelines for thromboprophylaxis after major orthopedic surgery: A systematic review of the literature and meta-analysis. Thromb Res. 2016;141:163-170. doi:10.1016/j.thromres.2016.03.029
13. Kanchanabat B, Stapanavatr W, Meknavin S, Soorapanth C, Sumanasrethakul C, Kanchanasuttirak P. Systematic review and meta-analysis on the rate of postoperative venous thromboembolism in orthopaedic surgery in Asian patients without thromboprophylaxis. Br J Surg. 2011;98(10):1356-1364. doi:10.1002/bjs.7589
14. Dashe J, Parisien RL, Pina M, De Giacomo AF, Tornetta P. Is the Caprini Score Predictive of Venothromboembolism Events in Orthopaedic Fracture Patients? J Orthop Trauma. 2019;33(6):269-275. doi:10.1097/BOT.0000000000001451
15. Sagi HC, Ahn J, Ciesla D, et al. Venous Thromboembolism Prophylaxis in Orthopaedic Trauma Patients: A Survey of OTA Member Practice Patterns and OTA Expert Panel Recommendations. J Orthop Trauma. 2015;29(10):e355-362. doi:10.1097/BOT.0000000000000387
16. Balk EM, Ellis AG, Di M, Adam GP, Trikalinos TA. Venous Thromboembolism Prophylaxis in Major Orthopedic Surgery: Systematic Review Update. Agency for Healthcare Research and Quality (US); 2017. Accessed August 28, 2021. http://www.ncbi.nlm.nih.gov/books/NBK476632/
17. Whiting PS, White-Dzuro GA, Greenberg SE, et al. Risk Factors for Deep Venous Thrombosis Following Orthopaedic Trauma Surgery: An Analysis of 56,000 patients. Arch Trauma Res. 2016;5(1):e32915. doi:10.5812/atr.32915
18. Mangwani J, Sheikh N, Cichero M, Williamson D. What is the evidence for chemical thromboprophylaxis in foot and ankle surgery? Systematic review of the English literature. Foot (Edinb). 2015;25(3):173-178. doi:10.1016/j.foot.2014.07.007
19. Perrotta C, Chahla J, Badariotti G, Ramos J. Interventions for preventing venous thromboembolism in adults undergoing knee arthroscopy. Cochrane Database Syst Rev. 2020;5:CD005259. doi:10.1002/14651858.CD005259.pub4
20. Falck-Ytter Y, Francis CW, Johanson NA, et al. 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
21. McLiesh P, Wiechula R. Identifying and reducing the incidence of post discharge Venous Thromboembolism (VTE) in orthopaedic patients: a systematic review. JBI Libr Syst Rev. 2012;10(28 Suppl):1-14. doi:10.11124/jbisrir-2012-315
22. Sobieraj DM, Coleman CI, Tongbram V, et al. Comparative effectiveness of combined pharmacologic and mechanical thromboprophylaxis versus either method alone in major orthopedic surgery: a systematic review and meta-analysis. Pharmacotherapy. 2013;33(3):275-283. doi:10.1002/phar.1206
23. Sobieraj DM, Lee S, Coleman CI, et al. Prolonged versus standard-duration venous thromboprophylaxis in major orthopedic surgery: a systematic review. Ann Intern Med. 2012;156(10):720-727. doi:10.7326/0003-4819-156-10-201205150-00423