Comparative Effectiveness

Extending use of anti-clotting medication following major orthopedic surgery may help prevent post-operative blood clots

For patients who have undergone major orthopedic surgery such as hip or knee replacement, extending post-surgery use of medications to prevent blood clots may be beneficial, according to a new review by the Agency for Healthcare Research and Quality (AHRQ). Blood clots in the legs, pelvis, lungs, or other areas, as well as other bleeding issues, are common among major orthopedic surgery patients. While current standard clinical practice recommends that patients take these medications for 7-10 days following surgery, the new research review finds that extending use to 28 days or longer may increase benefits.

Among the many types of available anti-clotting medications, there is not enough evidence to determine which type of medication is best. However, within the heparin class of medications, the review found that low molecular-weight heparin is superior to unfractionated heparin. The review calls for further studies to evaluate the use of medications after less serious types of orthopedic surgery. More research is also needed to compare the effectiveness of using one medication or combining multiple medications, as well as combining medications with other types of therapies, such as leg compression or foot pumps. The review also notes that there is not currently enough evidence to conclude that deep vein thrombosis, blood clots in the veins, causes pulmonary embolism, an often fatal blockage of the main artery of the lung.
To access the review, Venous Thromboembolism Prophylaxis in Orthopedic Surgery, and other AHRQ products, visit AHRQ's Effective Health Care Program Web site at http://www.effectivehealthcare.ahrq.gov.

Venous Thromboembolism Prophylaxis in Orthopedic Surgery

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Background

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.¹ However, prophylaxis with pharmacologic strategies also has limitations, including the risks of bleeding and prosthetic joint infections and the potential need for reoperation.
While prophylactic strategies may decrease the risk of VTE, deep vein thrombosis (DVT), and pulmonary embolism (PE) in major orthopedic surgery, the impact of VTE prophylaxis on orthopedic surgeries including knee arthroscopy, surgical repair of lower extremity injuries distal to the hip, and elective spine surgery has not been sufficiently evaluated. The magnitude of benefit and harms in contemporary practice with the use of rigorous endpoint definitions and evaluation of pharmacologic agents or devices available within the United States amongst the orthopedic surgery population is not well known. Additionally, the impact of duration of prophylaxis on outcomes, whether dual prophylactic therapy is superior to single modality therapy, and the comparative effectiveness of different pharmacologic or mechanical modalities have not been adequately systematically reviewed. Lastly, in contemporary practice, the risks of VTE, PE, and DVT and the causal link between DVT and PE have not been well established.²

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http://www.ahrq.gov/research/oct12/1012RA27.htm