Juan Sebastián Sánchez-Osorio, Adolfo Llinás, Guillermo Bonilla, Cristina Suarez, Daniel Monsalvo, Ana Torres, Sudeep Shivakumar, Justin Magnuson, Chad Kruger.
Response/Recommendation: Orthopaedic procedures carry variable risk profiles for deep venous thrombosis (DVT). They have been classically stratified according to the incidence of venous thromboembolism (VTE) events, with total hip arthroplasty (THA) and total knee arthroplasty (TKA) being the highest risk alongside hip fracture fixation.
Strength of Recommendation: Limited.
Rationale: Orthopaedic procedures do not have all the same profile risk for DVT. Risk for DVT arises from patient-related factors, the nature of the injury, the extent of the orthopaedic intervention, or the resulting immobility. The complex interaction of these risk factors has been termed thrombotic potential1.
Procedure-related factors such as surgery time-length, type of anesthesia, extent of tissue injury or trauma, site of surgery, and surgical technique2, are variables that may determine the variance in the prevalence of DVT from different surgical procedures. General anesthesia, for example, could favor an over-physiological muscle relaxation that produces a slower blood flow resulting in endothelial hypoxia, leukocyte adhesion, and the accumulation of activated coagulation factors3.
Traditionally, overall surgical procedures have been categorized as low-, intermediate-, high-, and very high-risk according to the incidence of symptomatic VTE4-6. The incidence of DVT after an orthopaedic procedure depends on the detection method used to assess the presence of thrombi. Although there is controversy about the relevance of asymptomatic DVT, it has been associated with recurrent VTE and post-thrombotic syndrome7.
THA and TKA, open reduction and internal fixation of hip fractures, and surgery due to major trauma are among the orthopaedic procedures with the highest DVT risk. With contemporary surgical protocols, the prevalence of VTE after THA has been reported to be up to 22%, using venography as a diagnostic method, even with the use of pharmacological prophylaxis8. THA has shown asymptomatic DVT events in 33% of patients, either with pharmacological, mechanical prophylaxis or both7.
For non-major orthopaedic surgery in the lower limb, including achilles tendon repair, surgery involving the tibial plateau or femoral diaphysis, tibial or ankle fractures or tibial osteotomy, arthrodesis of the knee, ankle, or hindfoot, among others, symptomatic DVT rates have resulted in 0,66% with the use enoxaparin or rivaroxaban9.Acetabular or pelvic reconstruction in a major trauma has an overall symptomatic DVT rate of 4% using low-molecular-weight heparin (LMWH)10.
For the upper extremity, data suggests that the greatest risk for DVT relates to personal or family history of thromboembolic events, active malignancy, prothrombotic disorders, and the presence of a central venous catheter11, instead of a patient undergoing a surgical procedure12.
Interestingly, certain surgeries are performed on patients with a demographic profile that adds risks factors for VTE unrelated to the procedure, but indirectly carries non-modifiable elements that magnify the procedure’s risk. An example of this is the TKA, a procedure commonly performed on patients with advanced age, obesity, certain degree of post-operative immobilization, and the indication of general anesthesia. Injury site influences the DVT risk for lower limb fractures, even before the added risk of fracture fixation13. Around the knee, around the hip, femoral shaft, tibiofibular, and ankle fractures have a DVT prevalence of 8.67%, 6.32%, 5.7%, 2.09%, and 1.97%, respectively13.
Recent studies have shown a decrease in symptomatic rates of VTE events as well as overall rates of surgical complications in the last decades14,15. This may be attributed to a combination of improvements in surgical techniques and perioperative care, including unicompartmental surgery, shorter operative procedure times, greater use of regional anesthesia, more effective analgesia, faster postoperative mobilization, increased use of day-case procedures, shorter duration of hospitalization, and more consistent use and/or longer duration of prophylaxis16.
The challenge of the quantification of the risk for DVT due to each intervention as an independent risk factor remains unresolved. A substitute for this void is the integral assessment of the thrombotic potential, an explicit declaration of adherence to a formal DVT prevention guideline aligned with the institutional value proposition, and a detailed informed consent 17.
- Rosendaal FR. Venous thrombosis: a multicausal disease. Lancet. 1999;353(9159):1167-1173.
- Parvizi J, Huang R, Raphael IJ, Arnold WV, Rothman RH. Symptomatic pulmonary embolus after joint arthroplasty: stratification of risk factors. Clin Orthop Relat Res. 2014 Mar;472(3):903-12
- Meissner MH, Wakefield TW, Ascher E, Caprini JA, Comerota AJ, Eklof B, Gillespie DL, Greenfield LJ, He AR, Henke PK, Hingorani A, Hull RD, Kessler CM, McBane RD, McLafferty R. Acute venous disease: venous thrombosis and venous trauma. J Vasc Surg. 2007 Dec;46 Suppl S:25S-53S
- White RH, Zhou H, Romano PS. Incidence of symptomatic venous thromboembolism after different elective or urgent surgical procedures. Thromb Haemost. 2003;90(3):446-455.
- Geerts WH, Heit JA, Clagett GP, et al. Prevention of venous thromboembolism. Chest 2001; 119(1 Suppl): 132S-75S
- Eichinger S, Kyrle PA. Prevention of deep vein thrombosis in orthopedic surgery. Eur J Med Res. 2004 Mar 30;9(3):112-8
- Song K, Xu Z, Rong Z, Yang X, Yao Y, Shen Y, Shi D, Chen D, Zheng M, Jiang Q. The incidence of venous thromboembolism following total knee arthroplasty: a prospective study by using computed tomographic pulmonary angiography in combination with bilateral lower limb venography. Blood Coagul Fibrinolysis. 2016 Apr;27(3):266-9.
- Verhamme P, Yi BA, Segers A, Salter J, Bloomfield D, Büller HR, Raskob GE, Weitz JI; ANT-005 TKA Investigators. Abelacimab for Prevention of Venous Thromboembolism. N Engl J Med. 2021 Aug 12;385(7):609-617.
- Samama CM, Laporte S, Rosencher N, Girard P, Llau J, Mouret P, Fisher W, Martínez-Martín J, Duverger D, Deygas B, Presles E, Cucherat M, Mismetti P; PRONOMOS Investigators. Rivaroxaban or Enoxaparin in Nonmajor Orthopedic Surgery. N Engl J Med. 2020 May 14;382(20):1916-1925.
- Elnahal WA, Bassett J, Acharya MR, Chesser T, Ward AJ. Incidence of DVT and PE after surgical reconstruction for pelvic and acetabular fractures: Does routine duplex scanning affect management? Eur J Orthop Surg Traumatol. 2021 Apr;31(3):491-495.
- Blom JW, Doggen CJ, Osanto S, Rosendaal FR. Old and new risk factors for upper extremity deep venous thrombosis. J Thromb Haemost. 2005;3:2471-8.
- Anakwe RE, Middleton SD, Beresford-Cleary N, McEachan JE, Talwalkar SC. Preventing venous thromboembolism in elective upper limb surgery. J Shoulder Elbow Surg. 2013 Mar;22(3):432-8.
- Chang W, Wang B, Li Q, Zhang Y, Xie W. Study on the Risk Factors of Preoperative Deep Vein Thrombosis (DVT) in Patients With Lower Extremity Fracture. Clin Appl Thromb Hemost. 2021 Jan-Dec;27:10760296211002900.
- Partridge T, Jameson S, Baker P, Deehan D, Mason J, Reed MR. TenYear Trends in Medical Complications Following 540,623 Primary Total Hip Replacements from a National Database. J Bone Joint Surg Am. 2018;100:360–7.
- Xu K, Chan NC, Ibrahim Q, Kruger P, Sinha S, Bhagirath V, et al. Reduction in mortality following elective major hip and knee surgery: a systematic review and meta-analysis. Thromb Haemost. 2019;119:668–74.
- Samama CM. Fast-track procedures in major orthopaedic surgery: is venous thromboembolism prophylaxis still mandatory? Thromb Haemost. 2019;119:003–5.
- Lapidus LJ, Rosfors S, Ponzer S, et al. Prolonged thromboprophylaxis with dalteparin after surgical treatment of Achilles tendon rupture: a randomized, placebo-controlled study. J Orthop Trauma. 2007;21(1):52-57.