This document summarizes deep vein thrombosis (DVT) prophylaxis for orthopedic surgeries. It discusses that without prophylaxis, the risk of DVT is 50% for orthopedic surgeries and the risk of fatal pulmonary embolism is 2.0-2.5% for hip replacement and 2.5-7.5% for fractured hip. It reviews various risk assessment models and prophylaxis methods, including mechanical methods like compression stockings and intermittent pneumatic compression, and pharmacological methods like low molecular weight heparins, warfarin, and newer oral anticoagulants. It provides comparisons of effectiveness and safety between different prophylaxis options. National guidelines for

1. DVT PROPHYLAXIS IN
ORTHOPEDIC SURGERIES
PRESENTED BY –DR SOUVIK PAUL
MODERATED BY –DR PRINCE RAINA

2. What Is Deep Vein
Thrombosis ?

3. INTRODUCTION
• WHAT IS VTE ?
• includes spectrum of deep vein thrombosis
(DVT) and pulmonary embolism (PE).

4. NEED OF DVT PROPHYLAXIS
.
common preventable cause of hospital deaths
DVT in traumatic injuries 5 - 63%
Without prophylaxis
venous thrombosis -- 50% Orthopedic surgeries
Fatal PE in 2.0% of total hip arthroplasty
Fatal PE in 2.5-7.5% of Fractured Hip
Ref: Campbell 12th edition
Piotrowski JJ, et al
Am J Surg. 1996 Aug; 172(2):210-3.

5. Indian J Urol. 2009 Jan-Mar; 25(1): 11–16.
doi: 10.4103/0970-1591.45531
INCIDENCE OF DVT IN DIFFERENT SURGERIES
Patient group VTE prevalence (%)
Medical patients 10-20
Cardiac patients 15-40
Neurosurgery 15-40
Stroke 20-30
Hip and knee arthroplasty 40-60
Major trauma 40-50
Spinal cord injury 60-80
Critical care patients 10-20

6. Strong risk factors
1. Hip or leg fracture
2. Hip or knee replacement
3. Major general surgery
4. Major trauma, including spinal cord injury

7. Moderate risk factors
1. Arthroscopic knee surgery
2. Central venous catheterization
3. HRT or OC Pills
4. Malignancy (active or recently treated)
5. Pregnancy
6. Paralytic stroke
7. Prior VTE
8. Thrombophilia (inherited or acquired)

8. Weak risk factors
1. Bed rest > 3d
2. Prolonged immobility
3. Advanced age
4. Laparoscopic surgery
5. Obesity
6. Pregnancy
7. Varicose veins

9. PATHOPHYSIOLOGY
• virchow's triad

10. Presentation and Physical
Examination
• Calf pain or tenderness
• Swelling + pitting oedema
• Increased skin temperature
and fever
• Superficial venous dilatation

11. Clinical examination
• Palpate distal pulses
• Evaluate capillary refill .
• Neurologic evaluation

12. • Homans sign:
pain posterior calf /knee with forced dorsiflexion of foot.
• Moses sign
Gentle squeezing of lower part of calf from side to side.
• Neuhofs sign
Thickening and deep tenderness elicited while palpating deep in calf muscles

13. Wells Clinical Prediction Guide
Variable Wells
Active cancer ( within last 6 months or palliative) 1
Calf swelling >3 cm compared to other 1
Collateral superficial veins 1
Pitting edema 1
Swelling of entire leg 1

14. variable wells
Paralysis, paresis, or recent cast immobilization of lower
extremities
1
Recently bedridden > 3 days, or major surgery 1
Previous DVT 1
Alternative diagnosis at least as likely deep vein thrombosis
-2
Localized pain along distribution of deep venous system 1

15. Interpretation
High probability: ≥ 3 (Prevalence of DVT - 53%)
Moderate probability: 1-2 (Prevalence of DVT - 17%)
Low probability: ≤ 0 (Prevalence of DVT - 5%)
Adapted from Anand SS, et al. JAMA. 1998; 279 [14];1094

16. Over 20 different VTE risk assessment
models
• Individualized point-based scoring models
e.g.:CAPRINI
PADUA
REVISED GENEVA SCORE
• Grouping or “bucket” models:
– NICE / NHS guidelines
– Classic “3 bucket” model

18. A TOTAL SCORE >4 INDICATES HIGH RISK OF VTE

20. Interpretation of revised Geneva score
0-3 score : low risk
4-10 score : intermediate risk
>11 score : high risk
.

21. • Validated in predicting risk
• Can be difficult to use reliably
Caprini Model

22. 1 point for each risk factors
• Age 41-60
• Swollen legs
• Varicose veins
• Obesity
• Sepsis
• OCP or HRT
• Pregnancy or postpartum
• AMI
• CHF
• Prolonged bed rest
• Prior major surgery

23. 2 points for each risk factors
• Age 61-74 yrs
• Arthroscopic surgery
• Malignancy
• Laparoscopic surgery
• Immobilisation with plaster cast (<1 month)

24. 3 points for each risk factor
• Age >75 yrs
• History of DVT /PE
• Positive factor leiden
• Family history of VTE
• Positive lupus anticoagulant
• HIT
• Elevated anticardiolipin antibodies

25. 5 points for each risk factors
• Stroke (<1 months)
• Elective major lower limb arthroplasty
• Hip ,pelvic , leg fractures(<1 month)
• Spinal cord injury (<1 month)

26. 1. Mechanical
2. Pharmacological

27. Mechanical
1. Physiotherapy
2. Graduated Compression Stockings (GCS)
3. Intermittent Pneumatic Compression Devices (IPC)
and Venous foot pumps (VFP).
4. IVC filters

28. Graduated Compression Stockings
(GCS)

29. Update of
Elastic compression stockings for prevention of deep vein
thrombosis. [Cochrane Database Syst Rev. 2010]
19 RCTs
1681 individual patients and 1064 individual legs (2745 analytic units).
9 TRIALS- general surgery,
6 TRIALS- orthopaedic surgery,
1 TRIAL- medical patients.
G c s applied on the day before surgery or on the day of surgery . worn up
until discharge or until the patients were fully mobile

30. Treatment group (GCS) of 1391 units -126 developed DVT
control group (without GCS) of 1354 units - 282 developed
DVT
odds ratio was 0.33
(95% CI) 0.26 to 0.41 (P < 0.00001).

31. INTERMITTENT PNEUMATIC
COMPRESSION [IPC]
• Inflation Cycle :10-20 secs
• Deflation cycle :30 secs

32. • At 40 mm Hg -maximum velocities with calf
and/or thigh compression –
Femoral velocity- 35–60 cm/s with augmentations at around 50–250%
popliteal velocities -55 cm/s.
At 120 mm Hg –
peak velocities of >100 cm/s in both popliteal and
femoral veins

33. • Foot compression has produced more modest results
20–40 cm/s -femoral vein
30–55 cm/s - popliteal vein

34. TYPES OF IPC

35. A: Venous blood flow velocity in the posterior tibial vein during compression by a foot cuff (velocity/ time
B: Venous blood flow velocity in the femoral vein during compression by a foot cuff (velocity [cm/s] vs. time [1
second per vertical dotted line]).

36. Problems in IPC
Improperly fitted compression stockings
reversed pressure gradient
higher incidence of VTE

37. CONTRAINDICATION OF IPC
• Severe arteriosclerosis
• Severe CHF
• Known acute DVT
• Gangrene
• Dermatitis
• Skin grafting

38. The Cochrane Peripheral Vascular Diseases Group Trials
RCT with 121 study participants comparing 2 types of IPC devices
• no cases of symptomatic DVT or PE during first 3 weeks after THR.
• calf-thigh pneumatic compression more effective
for reducing thigh swelling during early post-operative stage
Equal evidence regarding both types

39. DVT PUMP
• SET Pressures:
uniform thigh and calf / uniform calf garment 40 mmhg
sequential thigh and calf /sequential calf garment 45 mmhg
foot garment 130 mmhg

40. IVC filters
• FDA approved
• Ideal for young patients with reversible
PE risk factors

41. Indications
• Proven VTE
• Recurrent VTE
• Contraindications to anticoagulation
• Short Term Risk of PE/Short Term contraindication of anticoagulation
:retrievable filter
• Uncertain Risk of PE and/or lack of control for anticoagulation :
Permanent Filter
• Long Term Risk of PE/Recurrent PE/Recurrent DVT: Permanent Filter

42. SIDE EFFECTS
• Device-associated morbidity
• Device migration
• Filter embolization
• Filter fracture
• Insertion-site thrombosis
• Perforation of the vena cava
• Recurrent DVT
• Recurrent PE
• Thrombotic complications
• Vena cava thrombosis

43. Pharmacological:
1. Oral antiplatelet agents
2. Injectable low-molecular-weight heparins
3. Injectable unfractionated heparin
4. Injectable or oral factor Xa inhibitors
5. Injectable or oral direct thrombin inhibitors
6. Oral vitamin K antagonists

44. Oral antiplatelet agents
• Aspirin
Permanently inhibits COX-1 and COX-2
• Dipyridamole
Inhibits PDE; increases Camp
• Ticlopidine
• Clopidrgrel
• Abciximab
• Eptifibatide
• Tirofiban

45. Aspirin
• Dosage : 75 mg OD
• ACCP and AAOS guidelines do not include aspirin in prevention of VTE
• Present indications:
1.elective TKR
2.elective THR
3.contraindication to other pharmacologic prophylaxis

46. Contraindications to Antiplatelet Therapy
- Recent thoracic, abdominal, or cns surgery
-Recent CVA , trauma, or neoplasm
-Bleeding ulcer
-Hypertension
-Anticipated invasive procedures
-Concurrent hemostatic dysfunction

47. Heparin
• Types :
Un fractionated heparin(UFH) : inhibit factor II and X
Dose for DVT prophylaxis: 5000 u sc every 8 to 12 hours
Monitoring : aPTT
More risk for bleeding and heparin induced thrombocytopenia(8%)
Antidote: Protamine sulphate

48. LMWH
• Examples: enoxaparin, dalteparin, tinzaparin
• Inhibit thrombin only
• Dose in prophylaxis : 40 mg in 0.4 mL SC OD
• Lesser risk of and bleeding HIT
• No need to regular monitoring
• No antidote

49. Baseline Postoperative Risks of VTE Outcomes in the Absence of
Pharmacological Prophylaxis
•Outcome Total Hip
Replacement
Strength of
Evidence
(THR)
Total Knee
Replacement
Strength of
Evidence
(TKR)
Pulmonary
embolism
6% Low 1% Low
Deep vein
thrombosis
39% Low 46% Low
Major
bleeding
1% Moderate 3% Low
Minor
bleeding
5% Low 5% Moderate
Sobieraj DM, et al. Comparative Effectiveness Review No. 49. Available at
www.effectivehealthcare.ahrq.gov/thrombo.cfm

50. Comparative Effectiveness of Pharmacological Prophylaxis
Agents: LMWH Versus UFH
Comparators DVT PE Major
Bleeding
Heparin-induced
Thrombo-cytopenia
LMWH
vs. UFH
Decreased risk by
20%
RR 0.80
Decreased odds
by 52%
OR 0.48
Decreased odds
by 35%
OR 0.57
Decreased odds by
88%
OR 0.12
Sobieraj DM, et al. Comparative Effectiveness Review No. 49. Available at
www.effectivehealthcare.ahrq.gov/thrombo.cfm

51. warfarin
• Vitamin k antagonist
• Cause defective coagulation
• Slow in onset
• Good oral absorption
• Monitor with PT and INR

52. Comparative Effectiveness of Pharmacological
Prophylaxis Agents: LMWH Versus Warfarin
Comparators DVT Proximal
DVT
Symptomatic
VTE
PE
LMWH
vs. warfarin
Decreased risk
by 34%
RR 0.66
No difference;
RR 0.63
No difference;
OR 1.00
No difference;
OR 1.11
Sobieraj DM, et al. Comparative Effectiveness Review No. 49. Available at
www.effectivehealthcare.ahrq.gov/thrombo.cfm

53. Fondaparinux
– Synthetic Factor Xa inhibitor
– FDA approved for prophylaxis, treatment
• Prophylaxis: 2.5/d SC
• Treatment: weight based 5, 7.5 or 10/d SC
– Start warfarin simultaneously, continue 5-7 days as with heparin
• Avoid with GFR < 30

54. Comparative Effectiveness of Pharmacological Prophylaxis
Agents: Enoxaparin Versus Fondaparinux
Comparators DVT Symptomatic
VTE
PE Major
Bleeding
Enoxaparin
vs.
fondaparinux
Relative risk is
higher for
enoxaparin
by 99%
RR 1.99
No difference;
OR 0.70
No difference
OR 3.34
Decreased
odds by 35%
OR 0.65
Sobieraj DM, et al. Comparative Effectiveness Review No. 49. Available at www.effectivehealthcare.ahrq.gov/thrombo.cfm

55. Ximelagatran
• Direct thrombin inhibitors
• Alternative to warfarin
– Oral - fixed dose
• Acute clot or orthopedic prophylaxis: 36 mg bid
• Secondary prevention: 24 mg bid
– No monitoring, no initial heparin
• Safety questions
– No antidote
– Can elevate LFTs

56. NICE Guidelines 2015
Elective hip / knee replacement
Start mechanical VTE prophylaxis at admission
• anti-embolism stockings (GCS)
• foot impulse devices
• intermittent pneumatic compression (IPC)devices
Continue mechanical VTE prophylaxis until the patient no longer has significantly reduced
mobility.

57. If no contraindications, start pharmacological VTE prophylaxis after surgery
• dabigatran etexilate 1–4 hours after surgery
• fondaparinux sodium 6 hours after
• LMWH 6–12 hours after
• Rivaroxaban 6–10 hours after
• UFH (for renal failure patients) 6–12 hours after
Continue pharmacological VTE prophylaxis for 28–35 days in hip replacements
Continue pharmacological VTE prophylaxis for 10-14 days in knee replacements

58. • Hip fractures:
Start mechanical VTE prophylaxis at admission
•Anti-embolism stockings
•Foot impulse devices
•Intermittent pneumatic compression devices (thigh or knee length).
Continue mechanical VTE prophylaxis until the patient no longer has significantly
reduced mobility.

59. If no contraindications, start pharmacological VTE prophylaxis after surgery
• fondaparinux sodium not recommnded pre op,
can be given 6 hrs post op
• LMWH start at admission,
stop 12 hr before restart 6–12 hours after surgery
• Rivaroxaban 6–10 hours after
• UFH (for CRF) start at admission
stop 12 hr before Restart 6–12 hours after surgery
• Continue pharmacological VTE prophylaxis for 28–35 days

60. Other orthopaedic surgery
Start mechanical VTE prophylaxis at admission.
• Anti-embolism stockings
• Foot impulse devices
• Intermittent pneumatic compression devices (thigh or knee length).
Continue mechanical VTE prophylaxis until the patient no longer has
significantly reduced mobility.

61. Pharmacological VTE prophylaxis 6–12 hours after
surgery.
• LMWH
• UFH (for renal failure).
• Continue pharmacological VTE prophylaxis until patient no longer has
significantly reduced mobility.

62. DVT prophylaxis : ORTHOPEDICS SURGERY
• Low risk
– Early ambulation
• Moderate risk
– UFH 5000 u sc bid or LMWH, IPC
• High risk
– LMWH - may combine with IPC
AAOS Clinical Practice Guideline

63. Schematic of estimated incidence rates for LMWH and no prophylaxis for major orthopaedic
surgery
• Ref:Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American
College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
• Falck-Ytter Y1, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S, Ortel TL, Pauker SG, Colwell CW Jr;

64. Systematic Review – Regarding DVT Prophylaxis
 Meta regression analysis
 Compare other therapies to enoxaparin for prevention of
VTE following THR
Dranitsaris 2011
http://www.aaos.org/

66. Low-molecular-weight heparin and intermittent pneumatic compression for
thromboprophylaxis in critical patients
BING WAN, et al Oct 13. 2015 PMC
• 500 patients were divided into four groups
• IPC( int. Pneumatic compression) 95
• LMWH 185
• LMWH + IPC 75
• control 145
Doppler study diagnosis done

67. Incidence of DVT, PE and complications of treatment in
the four groups.
Group No. of patients DVT cases PE cases Bleeding cases
IPC 95 9 28 0
LMWH 185 31 4 18
LMWH + IPC 75 0 0 3
Control 145 49 29 0

68. conclusion
• LMWH combined with IPC exhibited an excellent prophylactic
effect against DVT and PE.
• RR : 0.281 for IPC,
• RR: 0.49 for LMWH.

69. Comparative efficacy and safety of anticoagulants and aspirin for
extended treatment of venous thromboembolism: A network
meta-analysis
Diana M. Sobieraj et al
systematic literature search and searching of reference lists
identify RCT of patients completed initial anticoagulant treatment for VTE
randomized for the extension study
comparison of anticoagulant treatment to placebo

70. .• Ten trials (n = 11,079) were included.
• Apixaban ,dabigatran, rivaroxaban, idraparinux and vitamin
K antagonists (VKA) reduced risk of VTE recurrence
compared to placebo.

71. COMPARATIVE EFFICACY AND SAFETY OF NEW ORAL ANTICOAGULANTS(NOAC)
VERSUS WARFARIN FOR LONG-TERM TREATMENT OF VENOUS THROMBOEMBOLISM:
A META-ANALYSIS
Ajay Vallakati et al
• We searched PubMed, Cochrane library and Embase for RCTs comparing
NOACs (dabigatran, apixaban, rivaroxaban, and edoxaban) with placebo or
warfarin for long-term treatment of VTE

72. 5 RCTs (n=16117) compared
NOACs (n=8484)
with either placebo (n=2085)
or warfarin (n=5548).
NOACs significantly reduced the risk of VTE
when compared to placebo/ warfarin (OR: 0.33; 95% CI, 0.13 −0.87)
• .

73. THANK YOU
•.