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Venous Thromboembolism Prophylaxis in Orthopedic Surgery [Internet]

Venous Thromboembolism Prophylaxis in Orthopedic Surgery [Internet]

Comparative Effectiveness Reviews - Agency for Healthcare Research and Quality (US)

Version: March 2012


Two literature searches were conducted as previously described in the methods. The first search was used to identify literature to answer Key Questions 1 through . Upon conducting this literature search, we retrieved 3,464 unique citations from the database search, 120 citations from a manual review of the literature, and two citations added manually from the gray literature search conducted by the Scientific Resource Center. Upon updating the literature search in May 2011, a total of 165 citations were retrieved. After duplicate citations were removed, 3,079 citations remained. A total of 2,426 citations were excluded at the title and abstract level while 656 citations were excluded at the full text level. A total of 177 articles were found to match our inclusion criteria. A summary of search results is presented in Figure 2. All citations excluded at the full text level are listed in Appendix C along with the reason for exclusion.


Major orthopedic surgery (total hip replacement, total knee replacement or hip fracture surgery) carries a high risk of venous thromboembolism. Pulmonary embolism following orthopedic surgery is reported to be rare. However, without prophylaxis, historical data suggest that hospital acquired deep venous thrombosis has been estimated to occur in 40 to 60 percent of cases in the 7 to 14 days following surgery compared with 10 to 40 percent among medical or general surgical patients. While asymptomatic deep vein thrombosis is identified more frequently than symptomatic deep vein thrombosis in clinical trials due to routine screening, there is disagreement as to the clinical relevance of asymptomatic cases., While certain patient characteristics (i.e. age, immobility, comorbidities) have been suggested to increase the risk of venous thromboembolism regardless of the clinical setting, major orthopedic surgery contributes additional factors such as use of general anesthesia which may prolong immobility and surgical involvement of the femoral vein.,

Executive Summary

Major orthopedic surgery describes three surgical procedures including total hip replacement (THR), total knee replacement (TKR), and hip fracture surgery (HFS). As a whole, major orthopedic surgery carries a risk for venous thromboembolism (VTE), and therefore, a variety of strategies to prevent VTE are available. Such strategies include pharmacological (antiplatelet, anticoagulant) and mechanical modalities that can be used alone or in combination. However, prophylaxis with pharmacologic strategies also has limitations, including the risks of bleeding and prosthetic joint infections and the potential need for reoperation.


A summary of the results with a strength of evidence rating of low, moderate, or high for Key Questions 1 through of our CER can be found in Table 4. Evaluations for Key Questions 9 through had insufficient strength of evidence and are not included. To see how our strength and applicability of evidence ratings were derived, please see Appendices H and . For more detailed analysis of our results or to see results for comparisons with an insufficient strength of evidence rating, please see the results section for that Key Question. Although major orthopedic surgery is inclusive of total hip or knee replacement surgery and hip fracture surgery, the vast majority of literature evaluated hip or knee replacement surgery with very little evaluation of hip fracture surgery. No literature was found evaluating health related quality of life or post thrombotic syndrome as outcomes while harms such as bleeding leading to infection, bleeding leading to transfusion, readmission, and reoperation were rarely reported. No trials or studies were found to evaluate the comparative effectiveness of inferior vena cava filters with mechanical prophylaxis in major orthopedic surgery whereas comparative data of prophylaxis to no prophylaxis or between injectable and mechanical prophylaxis in other nonmajor orthopedic surgeries was very limited.


The Evidence-based Practice Center drafted a topic refinement document with proposed Key Questions after consult with Key Informants. Our Key Informants included eight physicians: three provided the orthopedic surgeon's perspective one of which was a local expert, one provided a local pulmonologist's perspective, two provided expertise in methodology/guideline development, one provided a hematologist's perspective, and one provided expertise in health policy. There was equal representation from both the American College of Chest Physicians and the American Academy of Orthopedic Surgeons (three members each). Our Key Informants did not have financial or other declared conflicts. The public was invited to comment on the topic refinement document and Key Questions. After reviewing the public commentary, responses to public commentary, proposed revisions to the Key Questions, and a preliminary protocol was generated and reviewed with the Technical Expert Panel. The aforementioned Key Informants constituted our Technical Expert Panel and provided feedback on the feasibility and importance of our approach and provided their unique insight. Again, no conflict of interest was identified. The draft CER report underwent peer review and public commentary and revisions were made before finalizing the report.

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