Applying risk assessment models in orthopaedic surgery: overview of our clinical experience

Major joint surgery (elective hip or knee replacement, or hip fracture) carries a high risk of postoperative deep vein thrombosis (DVT) and pulmonary embolism. DVT prophylaxis has become an essential part of routine management, since several preventive methods, including low-molecular-weight heparins (LMWHs) and oral anticoagulants, are effective and safe in major joint surgery. Clinically important questions remain about the best way to use LMWHs for DVT prevention. The need for preoperative dosing, whether to give LMWHs once or twice daily, and the most suitable duration of prophylaxis remain issues of debate. Reports of local bleeding after spinal or epidural anaesthesia/analgesia in orthopaedic surgery patients given LMWH may make anaesthetists more reluctant to combine regional anaesthesia with LMWH prophylaxis, especially if a preoperative dose is required. The worldwide trend towards early transfer of postoperative patients from hospital to a convalescent facility or home has increased the need for formal recommendations about the optimal duration of prophylaxis. Ever shorter hospital admissions after elective surgery mean that prophylaxis given only in hospital may not be sufficient.