Vnitr Lek 2009, 55(3):204-210

Venous thromboembolism prophylaxis in orthopaedics and traumatology

P. Kessler

Oddělení hematologie a transfuziologie Nemocnice Pelhřimov, p.o., přednosta prim. MUDr. Petr Kessler

The paper formulates the following recommendations:
1. Patients with total hip or knee replacement should be prescribed higher prophylactic dose of low molecular weight heparin (LMWH) or fondaparinux or rivaroxaban or dabigatran, patients with proximal femur fracture should be prescribed higher prophylactic dose of LMWH or fondaparinux. Pharmacological prophylaxis should in patients with knee replacement be administered for at least 14 days and longer in patients with increased risk of venous thromboembolism (VTE). It is recommended that the prophylaxis lasts 28 to 35 days in patients with hip replacement or with a proximal femur fracture. Changeover to warfarin and its subsequent administration for 6-8 weeks can be used as an alternative where well-functioning anticoagulant treatment infrastructure is available. Intermittent pneumatic compression with subsequent pharmacological prophylaxis represents an alternative in bleeding patients or in patients with a high risk of bleeding. 2. Pharmacological prophylaxis is not needed in patients after knee arthroscopy without VTE risk factors in whom tourniquet was applied for < 60 min. Administration of LMWH for 5-7 days is suitable in patients after knee arthroscopy with VTE risk factors or in whom tourniquet was applied for > 60 min., administration of LMWH for 3 weeks is recommended in patients after the arthroscopic anterior cruciate ligament surgery. 3. Administration of LMWH for 7-10 days is indicated in patients with lower limb (LL) fractures treated with osteosynthesis. LMWH administration for the period of the fixation is indicated in patients with LL injury requiring plaster cast or other fixation above the knee. Administration of LMWH for the period of the fixation is indicated in patients with LL injury requiring plaster cast fixation below the knee that have increased VTE risk. 4. IPC or leg pump is recommended in patients with severe trauma who are bleeding or have a high risk of extensive bleeding. Administration of LMWH should be started as soon as the risk of extensive bleeding dissipates. Computer tomography (CT) or nuclear magnetic resonance imagining (NMRI) should be performed in patients with spinal injury with incomplete spinal lesion to exclude perispinal haematoma. Should haematoma occur, IPC should be used and CT or NMRI repeated after a few days; it is recommended to commence LMWH administration only when the haematoma had been stabilized. In case of persisting immobility, continuing LMWH or warfarin prophylaxis is recommended.

Keywords: venous thromboembolism; prophylaxis; LMWH; warfarin; orthopaedic surgery; trauma

Received: February 1, 2009; Published: March 1, 2009  Show citation