Venous thromboembolism remains a major cause of morbidity and mortality among patients undergoing major orthopaedic surgery. With improved surgical techniques, the use of heparin-based thromboprophylactic agents has allowed significant advances in the prevention of thrombosis during the past 30 years. With an aging population and the growing burden of degenerative joint disease, the management of this preventable disease remains at the forefront of surgical care. Despite the use of the supposedly most effective antithrombotic agents (low-molecular-weight heparins), recent studies have highlighted considerable prevalence of thrombosis, especially among hip fracture patients. New prevention strategies include a greater use of existing therapies, combining chemical and mechanical methods, extending the duration of prophylaxis and, most importantly, developing more effective agents with improved benefit to risk ratios.