Venous Thromboembolism Prophylaxis in Orthopedic Surgery
Establishing the Need for a Systematic Review of VTE Prophylaxis in Orthopedic Surgery
There are many unknowns that need to be explored in a comparative effectiveness review. In contemporary practice, the risk of venous thromboembolism (VTE), pulmonary embolism (PE), and deep vein thrombosis (DVT) and the causal link between DVT and PE have not been well established. Previous observations of the incidence of PE in patients who have undergone orthopedic surgery with confirmed DVT suggests that PE and DVT are related disorders. However, whether the presence of DVT affects the risk of PE, and to what degree if so, remains unclear in the literature. Widespread use of anticoagulants to treat VTE for many decades, along with the evolution of diagnostic strategies, have limited the availability of literature regarding the natural history of VTE. In addition to major orthopedic surgery, there are a variety of other orthopedic surgeries in which the impact of venous thromboembolic prophylaxis has not been well evaluated. These orthopedic surgeries of interest include knee arthroscopy, surgical repair of lower extremity injuries distal to the hip, and elective spine surgery. While prophylactic strategies may decrease the risk of VTE, PE, and DVT, the magnitude of benefit in contemporary practice using rigorous definitions of end points and the impact of duration of prophylaxis on outcomes are not well delineated. Whether dual prophylactic strategies are superior to a single modality is not well defined. In addition, in order to determine comparative effectiveness, both the benefits and harms need to be appreciated. Finally, several previous meta-analyses and guidelines allowed the use of medications or devices that are not available for use in the United States thereby reducing their applicability.
- American Academy of Orthopaedic Surgeons. Guideline on preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. Available at www.aaos.org/research/guidelines/VTE/VTE_guideline.asp. Accessed August 2, 2012.
- Egermayer P, Town GI. The clinical significance of pulmonary embolism: uncertainties and implications for treatment—a debate. J Intern Med 1997;241:5-10. PMID: 9042087.
- Eikelboom JW, Karthikeyan G, Fagel N, et al. American Association of Orthopedic Surgeons and American College of Chest Physicians guidelines for venous thromboembolism prevention in hip and knee arthroplasty differ: what are the implications for clinicians and patients? Chest 2009;135:513-20. PMID: 19201714.
- Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008;133(6 Suppl):381S-453S. PMID: 18574271.
- Goodman LR. Small pulmonary emboli: what do we know? Radiology 2005;234:654-8. PMID: 15734923.
- Haas SB, Barrack RL, Westrich G, et al. Venous thromboembolic disease after total hip and knee arthroplasty. J Bone Joint Surg Am 2008;90:2764-80. PMID: 19047723.
Your slide tray is being processed.