Prophylaxis of venous thromboembolism in major orthopedic surgery: a practical approach

Deep venous thrombosis (DVT) is a common cause of morbidity after orthopedic surgery, both in the early post operative period when pulmonary embolism may complicate in hospital clinical course or occur after discharge and later due to development of post thrombotic syndrome. At present, clear evidence has been provided that pharmacological primary prophylaxis of venous thromboembolism (VTE) is associated with an impressive decrease in the incidence of DVT and related complications. The main limitation of VTE prophylaxis with anticoagulant drug is the risk of bleeding. Both pharmacological and non pharmacological measures are available and indication, clinical results and limitations will be discussed for each. For drug prophylaxis at present mainly are used as parenteral agents, low dose un fractionated heparin, low molecular weight heparin and fondaparinux; however, limited compliance may be a concern. Newer oral anticoagulants, dabigatran, rivaroxaban and apixiban, may be indicated in elective surgery in particular in patients with expected poor adherence to parenteral route. Non pharmacological treatment includes measures directed to decrease the effects of blood stasis, intermittent pneumatic compression device (IPCD) and graduated compression stockings, mechanical devices, inferior caval vein filters. Aim of the present review was to suggest practical approach to DVT prophylaxis in patients undergoing major orthopedic surgery.