ABSTRACT
As medical standards for the prevention of perioperative venous thromboembolism have been established, new challenges have arisen in the management of patients having orthopedic surgery and neuraxial and peripheral blocks. Patients undergoing major orthopedic surgery, including hip and knee arthroplasty and repair of hip fracture, are at particularly high risk for venous thromboembolism. Routine thromboprophylaxis has been the standard of care for nearly 2 decades. The most recent recommendations of the American College of Chest Physicians regarding prevention of thromboembolism in patients undergoing total joint replacement or repair of hip fracture include three anticoagulant regimens:
• Low-molecular-weight heparin (LMWH) therapy started 12 hours preoperatively, or 12 to 24 hours postoperatively, or 4 to 6 hours postoperatively at half the usual dose and the dose is increased to the usual high-risk dose the following day
• Fondaparinux (2.5 mg 6-8 hours postoperatively) • Adjusted-dose warfarin started preoperatively or the evening after operation
(target international normalized ratio [INR], 2.5; INR range, 2.0-3.0)
Intermittent pneumatic compression is an alternative to anticoagulant prophylaxis in patients undergoing total knee (but not hip) replacement.
