Version May 2024
INTRODUCTION — Non-major orthopedic surgery includes a variety of lower extremity and upper extremity surgeries that do not include major orthopedic surgeries such as total hip arthroplasty, total knee arthroplasty, hip fracture repair, and severe trauma-related orthopedic surgery (ie, pelvic fracture, severe extremity injury). While the risk of venous thromboembolism (VTE; deep venous thrombosis, pulmonary embolism) is considered high for those undergoing major lower extremity orthopedic surgery, the risk of VTE is generally much lower in those undergoing non-major orthopedic surgery, although the range of risk is wide and the population is less well studied.
Our approach to VTE prevention in adults undergoing non-major extremity orthopedic surgery is discussed in this topic and is consistent with approaches issued by the American College of Chest Physicians and the American Society of Hematology [1,2].
VTE prevention in patients undergoing major orthopedic surgery, trauma-related orthopedic surgery, and nonorthopedic surgery are discussed separately.
●(See "Venous thromboembolism risk and prevention in the severely injured trauma patient".)
●(See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)
TYPES OF NON-MAJOR ORTHOPEDIC EXTREMITY SURGERY — Non-major extremity orthopedic procedures are a heterogeneous group that includes the following:
●Repair of long bone above-knee fracture (eg, femur, tibial plateau) and below-knee fracture (eg, tibia, fibula, tibia-fibula) not involving the hip or knee joint and repair of soft tissue injury (which may or may not occur in association with long bone fracture) such as quadriceps and patellar tendon ruptures. (See 'Isolated long bone above- and below-knee fracture/soft tissue injury' below.)
●Arthroscopy or arthroscopic surgery of the knee and hip. (See 'Knee arthroscopic surgery' below and 'Upper extremity procedures' below.)
●Bone, joint, or soft tissue surgery of the ankle/foot (eg, ankle arthroscopy, carpal or tarsal bone fracture, fusion, arthrodesis, amputation, hallux valgus repair, Achilles tendon repair). (See 'Foot and ankle surgery' below.)
●Shoulder/elbow/wrist/hand surgery (eg, fracture and non-fracture-related surgery or arthroscopy of the shoulder, rotator cuff repair; fracture surgery of the humerus, radius, or ulna; repair of elbow or wrist fracture; and carpal bone fracture or carpal tunnel release, digital repair). (See 'Upper extremity procedures' below.)
We will not be discussing surgeries involving free flap reconstruction or replantation, or trauma-related orthopedic surgery (eg, concomitant head trauma, multiple severe fractures, concomitant nerve or vascular injury), which are often high risk for VTE and are reviewed separately. (See "Surgical reconstruction of the lower extremity" and "Flap reconstruction of the lower extremity" and "Venous thromboembolism risk and prevention in the severely injured trauma patient" and "Prevention of venous thromboembolism in adults undergoing hip fracture repair or hip or knee replacement".)
GENERAL RISK ASSESSMENT — In patients undergoing non-major orthopedic surgery of the extremity (ie, other than hip or knee arthroplasty, hip fracture repair, or severe trauma-related orthopedic surgery), we assess the risk of postoperative VTE and bleeding to evaluate the need for and safety of thromboprophylaxis.
Risk of thrombosis — For patients undergoing non-major orthopedic surgery, we take a full history and examination to assess the baseline risk of the surgical procedure and other patient-specific or procedure-related risk factors for VTE. In this population, there are no validated tools to accurately estimate VTE risk. While preliminary data suggest possible value [3], we do not typically use the Caprini score (table 1) since the score has yet to be properly validated in orthopedic surgery patients [4,5].
●Baseline risk – The baseline risk of VTE in patients undergoing non-major extremity orthopedic surgery is generally considered low (eg, <2 percent risk of VTE in the first three months following surgery). The generally younger age of this population and more active lifestyle compared with patients undergoing major lower extremity orthopedic surgery may contribute to the lower risk. Furthermore, early mobilization/ambulation of patients has been a significant driver of reducing post-operative VTE risk. Data describing the baseline VTE risk in this population are largely derived from observational studies, which are discussed in more detail in the sections below. (See 'Lower extremity procedures' below and 'Upper extremity procedures' below.)
●Additional risk factors – When assessing VTE risk, we also evaluate for additional patient-specific or procedure-related risk factors (table 2) that may augment the risk above baseline:
•Patient-specific factors that increase the risk of VTE include previous VTE, family history of VTE, and active cancer, among others (table 2). (See "Overview of the causes of venous thrombosis".)
•Several procedure-related factors can also increase the risk of VTE. These include the following:
-The extent and duration of surgery (the greater the extent and duration, the higher the risk).
-Extended use of intraoperative tourniquet (although this is controversial).
-The type of anesthesia (general anesthesia has a higher risk compared with local anesthesia).
-Immobilization and casting postoperatively (immobilization and casting increase the risk).
-Select surgeries at high risk of VTE such as femur fracture, fractures around the knee, and Achilles tendon repair (eg, >2 percent risk VTE in first three months following surgery). (See 'Isolated long bone above- and below-knee fracture/soft tissue injury' below and 'Foot and ankle surgery' below.)
Risk of bleeding — For patients undergoing non-major extremity orthopedic procedures in whom pharmacologic thromboprophylaxis is warranted, we obtain a full history and examination to assess the risk of major bleeding. Major bleeding is defined as fatal bleeding, symptomatic bleeding in a critical area or organ, bleeding causing a fall in hemoglobin of ≥2 g/dL or leading to transfusion of two or more units of whole blood or red cells, or bleeding requiring reoperation [6].
●Baseline risk – The American College of Chest Physicians and others have estimated that the average baseline bleeding risk in nontrauma patients is low and approximately <2 percent (table 3) [1,7]. However, estimates are largely derived from patients undergoing major lower extremity orthopedic surgery such as hip or knee arthroplasty or hip fracture repair. Other factors that may be affecting accurate estimates are the increasing use of thromboprophylaxis, improvements in surgical techniques, and the inclusion in trials of only patients with a low risk of bleeding.
●Additional risk factors – We also take into consideration additional patient-specific and procedure-related risk factors. Patient-specific factors may also increase the bleeding risk. These include conditions that represent contraindications to pharmacologic thromboprophylaxis (eg, active bleeding), bleeding diatheses, thrombocytopenia (eg, platelet count <50,000/microL) (table 4), or conditions in which bleeding is potentially catastrophic. Epistaxis and menstrual bleeding are not contraindications to pharmacologic thromboprophylaxis.
Most experts consider open shoulder surgery (eg, total shoulder arthroplasty) and some foot surgeries (eg, Achilles tendon surgery) to have a higher risk of bleeding (2 to 4 percent) [8-11] while other procedures like arthroscopy and hand surgeries (eg, carpal tunnel release) have a lower bleeding risk (<2 percent) [12].
Use of tranexamic acid as an agent to control bleeding may decrease the risk of bleeding, if used [13].
LOWER EXTREMITY PROCEDURES — This includes patients with bony and soft tissue injury repair and patients undergoing knee and foot/ankle surgery. (See 'Types of non-major orthopedic extremity surgery' above.)
The content in this section does not apply to patients undergoing major lower extremity orthopedic procedures (eg, hip arthroplasty, knee arthroplasty, hip fracture repair), patients with severe trauma-related orthopedic or other surgery (eg, concomitant head trauma, multiple severe fractures, concomitant nerve or vascular injury), or surgeries involving free flap reconstruction or replantation. These data and protocols for thromboprophylaxis in these populations are reviewed separately. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients" and "Venous thromboembolism risk and prevention in the severely injured trauma patient", section on 'Pelvis or extremity injury' and "Surgical management of severe lower extremity injury", section on 'VTE prophylaxis'.)
Isolated long bone above- and below-knee fracture/soft tissue injury — This includes repair of long bone above-knee fractures (eg, femur, tibial plateau), fractures around the knee, below-knee fractures (eg, tibia, fibula, tibia-fibula), and quadriceps and patella tendon repairs. (See 'Types of non-major orthopedic extremity surgery' above.)
Recommendation — For patients who undergo surgical repair of an isolated long bone above- or below-knee fracture/soft tissue injury that is considered at high risk of VTE, we suggest pharmacologic thromboprophylaxis rather than no prophylaxis, provided that the bleeding risk is low; this includes femoral shaft fracture, femoral neck, inter- or subtrochanteric fracture, tibial plateau fracture, patellar fracture, realignment procedures such as tibial osteotomy, and/or surgery requiring prolonged immobilization or casting. For all other patients, we suggest early and frequent ambulation rather than pharmacologic thromboprophylaxis unless patient-specific factors that place the individual at high risk for VTE are present (eg, previous VTE) (table 2).
When thromboprophylaxis is chosen, we suggest low molecular weight (LMW) heparin or rivaroxaban. However, the optimal agent is unknown and practice varies widely. Aspirin is frequently administered in this population, particularly in individuals with low thrombotic risk who are not yet weight-bearing, although data comparing aspirin to other approaches are indirect and dosing varies widely (eg, 81 mg/day to 325 mg/day). Prophylaxis is generally administered for the period of immobilization or casting.
This approach is based upon evidence that has consistently demonstrated that the spectrum of risk for VTE is wide in this population (<1 to 6 percent) (see 'Venous thromboembolism risk' below), suggesting that select patients on the higher end of this risk range may benefit from pharmacologic thromboprophylaxis while thromboprophylaxis may not be justified for those on the lower end of this risk. For those in whom pharmacologic thromboprophylaxis is administered, data suggest that thromboprophylaxis may impact VTE rates by preventing asymptomatic or distal deep vein thrombosis (DVT) rather than symptomatic disease (ie, VTE that is clinically significant and at risk of embolization). (See 'Efficacy of pharmacologic prophylaxis' below.)
Venous thromboembolism risk — The risk of VTE with isolated long bone above-and below-knee fracture/soft tissue injury varies but is on average <2 percent (range <1 to 6 percent) [14-22]. On the higher end of the range are patients with femur fracture repair and those with injury that is closer in proximity to the hip or knee [17,21]. Fractures actually involving the hip (eg, femoral neck fracture, intertrochanteric fracture, subtrochanteric fracture) or knee joint (eg, distal femur, tibial plateau, patellar fracture) or realignment procedures like tibial osteotomy have a higher VTE risk that is similar to hip or knee repair/replacement procedures [19]. VTE risk in patients undergoing major orthopedic surgery is reviewed separately. (See "Prevention of venous thromboembolism in adults undergoing hip fracture repair or hip or knee replacement".)
Data that support this low risk in this population are typically derived from small retrospective studies [14,17-19,22]:
●In a randomized trial of patients undergoing casting of the lower leg (requiring surgical or conservative management), the rate of symptomatic VTE was 1.8 percent among those who did not receive VTE prophylaxis [18].
●A multicenter prospective cohort study included patients with a tibia, fibula, or ankle fracture (treated nonoperatively) or a patellar or foot fracture (treated operatively or conservatively). Thromboprophylaxis was not allowed during the study. The overall rate of symptomatic VTE was 7 of 1200 (0.6 percent) [14]. Two had proximal DVT; three had calf vein thrombosis; and two had pulmonary embolism (PE).
●In another trial of patients with isolated below-knee fractures, the incidence of VTE after surgically repaired, isolated tibia, fibula, or ankle fracture was 1.9 percent among those who did not receive thromboprophylaxis [22].
●In a nationwide review, the incidence of VTE during the 180-day study period following surgery for a fracture distal to the knee was 594 of 57,619 (1 percent) [17]. The patients in this study received thromboprophylaxis perioperatively, which was discontinued at discharge.
●In a review of hospitalized patients with isolated patella fracture, DVT occurred in 29 of 716 patients (4.1 percent), with one patient having bilateral limb involvement [19].
Typical patient-specific and procedure-related issues contributing to an increased risk of VTE following extremity fracture include older age, preinjury immobility, type of surgery, and immobilization and casting, which is common following fracture surgery. (See 'Risk of thrombosis' above.)
Efficacy of pharmacologic prophylaxis — Data to support anticoagulant prophylaxis in individuals undergoing surgery for isolated lower limb fracture/soft tissue injury are fraught with several methodologic limitations. These include low event rates, heterogeneity in patient outcomes (eg, symptomatic or asymptomatic DVT), a large variety of noncomparable injuries/surgeries, and patient inclusion (eg, inclusion of only low-VTE risk patients or patients with a wide VTE risk range), and early cessation of one trial [18,20,22-29].
●In a meta-analysis of eight randomized trials totaling almost 3680 patients with lower leg immobilization (included patients from POT-CAST below [18] but not PRONOMOS below [23]), the incidence of symptomatic and asymptomatic VTE was lower among patients using LMW heparin compared with placebo (odds ratio [OR] 0.45) [20]. However, the range of VTE rates was wide (0 to 37 percent [LMW heparin] versus 4 to 40 percent [placebo]; OR 0.45, 95% CI 0.33-0.61; moderate-quality evidence). Results were consistent across subcategories: operated patients, conservatively treated patients, patients with fractures, patients with soft-tissue injuries, patients with proximal or symptomatic thrombosis, patients with distal thrombosis, and patients with below-knee casts (low-quality evidence). Major bleeding events were rare (0.3 percent), and the rate of PE was no different among the groups.
●In an open-label randomized trial (POT-CAST) of 1519 patients undergoing casting of the lower leg (requiring surgical or conservative management), the rate of symptomatic VTE was similar among those receiving LMW heparin for the full period of immobilization compared with those not receiving anticoagulant therapy (1.4 versus 1.8 percent) [18]. No major bleeding events occurred in either group. However, patients with a higher risk of VTE (eg, patient with previous VTE or active cancer) were excluded from this study.
●In another randomized trial (from PRONOMOS investigators) of 3604 patients who were immobilized after less extensive lower limb orthopedic surgery (eg, knee ligament repair, ankle surgery), rivaroxaban (10 mg orally daily) was associated with a reduction in both symptomatic and asymptomatic VTE compared with patients treated with enoxaparin (40 mg subcutaneously once daily) (0.2 versus 1.1 percent for overall VTE rate; 0.2 versus 0.6 for symptomatic VTE) [23]. There was no difference in the rates of major bleeding between the groups (approximately 1 percent). However, interpretation of these results is limited, given that a sizeable proportion of VTE events were asymptomatic or had distal DVT (which is less likely to embolize). In addition, the study was stopped early due to poor enrollment, and the overall event rate was low.
Data to support aspirin in this population are also limited and indirect. Aspirin was compared with LMW heparin in a trial of over 12,000 patients (METRC) with polytrauma who underwent surgical treatment for fracture (two-thirds of patients had a lower extremity fracture excluding tarsal and meta-tarsal surgery) [30]. There was no difference in the rate of DVT (2.51 [aspirin] versus 1.71 percent [LMW heparin]), PE (1.5 percent in each group) or bleeding (14 percent each). However, most of these patients were young and had low risk for VTE. This study is discussed in detail separately. (See "Venous thromboembolism risk and prevention in the severely injured trauma patient" and "Prevention of venous thromboembolism in adults undergoing hip fracture repair or hip or knee replacement", section on 'Aspirin'.)
Knee arthroscopic surgery — This encompasses patients who undergo arthroscopic surgery of the knee. (See 'Types of non-major orthopedic extremity surgery' above.)
●Recommendation – Pharmacologic thromboprophylaxis is controversial in patients undergoing knee arthroscopic surgery, which is largely performed on an outpatient basis in otherwise young, healthy individuals. We do not routinely administer pharmacologic thromboprophylaxis in this population since the risk of symptomatic VTE appears to be low in this population. However, we advocate for an individualized approach since the individual risk may be higher in some patients compared with others. As an example, for those without additional risk factors over and above the baseline risk who are ambulatory, withholding pharmacologic thromboprophylaxis is reasonable. In contrast, for patients with additional patient-specific (eg, older age, prior DVT, contraceptive medications) (table 2) or procedure-specific risk factors for VTE (eg, prolonged surgery >1.5 hours), pharmacologic prophylaxis may be advisable, provided that the bleeding risk is low.
For those in whom pharmacologic prophylaxis is chosen, we prefer LMW heparin, although aspirin is frequently administered, particularly in individuals with low thrombotic risk who are not yet weight-bearing.
●Baseline VTE risk – Several retrospective studies of patients undergoing knee arthroscopic surgery report a low risk of VTE in this population ranging from 0.002 to 0.55 percent [18,31-38]:
•Best illustrating this is a Cochrane review of eight studies involving nearly 4000 patients undergoing knee arthroscopy that reported that among healthy adults, the risk of VTE was 0.002 percent and found little or no benefit from LMW heparin or rivaroxaban in this setting [38].
•In the POT-KAST trial, among patients undergoing knee arthroscopy who did not receive thromboprophylaxis, VTE occurred in 8 of the 1451 (0.55 percent) patients [18].
Patient-specific risk factors from these studies included older age, prior DVT, and contraceptive medications [31,35,36]. Procedure-related risk factors associated with VTE after knee arthroscopy include prior surgery within 30 days and operating room time >1.5 hours. The type of arthroscopic surgery does not appear to alter risk.
●Efficacy of pharmacologic thromboprophylaxis – Data describing the risk benefit of pharmacologic thromboprophylaxis in patients undergoing arthroscopy and arthroscopic-assisted procedures of the knee are limited [18,38-44]:
•A systematic review of eight studies involving nearly 4000 patients undergoing knee arthroscopy found little or no benefit from LMW heparin or rivaroxaban in this setting (risk ratio [RR] for PE 1.81, 95% CI 0.49-6.65, moderate certainty evidence; RR for symptomatic DVT 0.61, 95% CI 0.18-2.03, moderate-certainty evidence; RR for asymptomatic DVT 0.14, 95% CI 0.03-0.61, very low-certainty evidence) [38]. There was no evidence of a clear effect on major bleeding (RR 0.98, 95% CI 0.06-15.72, moderate-certainty evidence). A similar lack of benefit was reported for those taking rivaroxaban or aspirin.
•In the POT-KAST trial, among 1543 patients undergoing arthroscopy, the rate of symptomatic VTE was similar in patients treated with LMW heparin (for eight days) compared with those not receiving prophylactic anticoagulation (0.7 versus 0.4 percent) [18]. There were no major bleeding events in either group (0.1 percent each). However, in this trial, event rates were low and high-risk patients were excluded.
•Another trial (ERIKA) randomly assigned 241 patients to rivaroxaban or placebo for seven days after knee arthroscopy [40]. The primary composite outcome (all-cause death, symptomatic thromboembolism, asymptomatic proximal DVT at three months) occurred in significantly fewer patients in the rivaroxaban group compared with placebo (0.8 versus 6.1 percent; absolute risk difference -5.3 percent, 95% CI -11.4 to -0.8). No major bleeding was observed. The small sample size, inclusion of asymptomatic events, high exclusion rate, and low number of reconstruction procedures are limitations of this study.
Hip arthroscopy — Hip arthroscopy is a rare procedure. For patients who undergo hip arthroscopy, we follow the same principles as for arthroscopic knee surgery. (See 'Knee arthroscopic surgery' above.)
Two large database studies looked at the incidence of VTE following hip arthroscopy and found the overall incidence to be less than 1 percent (0.6 to 0.77 percent) [45,46]. Risk factors included obesity, chronic obstructive pulmonary disease, malignancy, tobacco use, and diabetes [45,46].
Foot and ankle surgery — Foot and ankle surgery includes a wide range of bone, joint, or soft tissue surgery of the ankle/foot (eg, ankle arthroscopy, tarsal bone fracture, fusion, amputation, hallux valgus repair, Achilles tendon repair). (See 'Types of non-major orthopedic extremity surgery' above.)
●Recommendation – We do not routinely administer pharmacologic thromboprophylaxis in patients undergoing foot and ankle surgery given the generally low incidence of VTE (ie, <1 percent). However, we advocate an individualized approach that reserves prophylaxis for those who are considered at a high risk of VTE, provided that the bleeding risk is low. For example, we consider that pharmacologic prophylaxis is reasonable in those with procedure-specific risk factors (eg, Achilles tendon repair, prolonged immobilization is expected such as surgery for neuropathic arthropathy [ie, Charcot foot]) or patient-specific risk factors for VTE (eg, previous VTE, multiple risk factors or a family history of VTE, patients with an underlying thrombophilic disorder, active cancer). (See "Surgical management of neuropathic arthropathy (Charcot foot)".)
When pharmacologic prophylaxis is indicated, we prefer LMW heparin. We continue prophylaxis until the patient is mobile. Data suggest that aspirin is also widely prescribed in this population [47].
●VTE risk – Foot and ankle surgery procedures have an overall low risk of VTE (eg, <1 percent risk of symptomatic VTE in the first three months following surgery) [24,25,29,47-55]. However, as an exception, DVT is common with Achilles tendon rupture [25,56].
•In a systematic review of six trials in patients undergoing isolated foot or ankle surgery, the incidence of VTE in those who did not receive thromboprophylaxis was 0.56 percent [29].
•In another systematic review, among 43,381 patients undergoing foot and ankle surgery, the incidence of symptomatic VTE was 0.4 percent [24], but the rate was higher when radiographically evident DVT was included in the analysis (ie, asymptomatic DVT; 10 percent).
•Among those undergoing foot and ankle surgery, the risk of VTE is highest in patients with Achilles tendon rupture (7 percent for symptomatic DVT and 35 percent for symptomatic plus asymptomatic DVT) [24,25].
In these studies, patient-specific risk factors for VTE included hormone replacement, oral contraceptive use, increasing age, prior VTE, increased body mass index, inpatient status, malignancy, factor V Leiden, and nonelective surgery, non-weight bearing, and immobilization [15,24,50].
●Efficacy of pharmacologic thromboprophylaxis – One meta-analysis of six low quality studies reported that VTE prophylaxis resulted in a lower risk for VTE (RR 0.72, 95% CI 0.55-0.94) without any change in the risk for bleeding, although the confidence limits for the latter were wide (RR 2.12, 95% CI 0.53-8.56) and the event rates for symptomatic DVT were very low [29].
UPPER EXTREMITY PROCEDURES — This encompasses patients undergoing shoulder/elbow/wrist/hand surgery such as fracture and non-fracture-related surgery or arthroscopy of the shoulder, rotator cuff repair; fracture surgery of the humerus, radius, or ulna; repair of fractures around the elbow or wrist; and carpal bone fracture or carpal tunnel release, digital nerve or tendon repair (See 'Types of non-major orthopedic extremity surgery' above.)
When deep vein thrombosis (DVT) occurs, it is often related to the operated upper extremity rather than affecting the lower extremity.
●Recommendation – Given the generally low incidence of VTE among patients undergoing upper extremity orthopedic procedures, we do not routinely administer pharmacologic thromboprophylaxis in this population. We advocate an individualized approach that reserves prophylaxis for those who are considered at a high risk of VTE (eg, high risk procedure such as humerus fracture, anticipated prolonged immobilization; patient-specific factors such as prior VTE, thrombophilic disorder, multiple risk factors, family history of VTE), provided that the bleeding risk is low.
In most cases when patients are considered at high risk of VTE, we prefer low molecular weight heparin, although in practice aspirin is frequently administered to many patients regardless of their risk.
●VTE risk – Most studies in this population have reported rates of symptomatic VTE that are <1 percent [57-69]. Rare retrospective case series have reported higher rates [70-72]. As examples:
•In a systematic review that included over 12,000 shoulder arthroplasties from nine studies, the overall incidence of VTE was 0.81 percent (0.54 percent DVT, 0.33 percent pulmonary embolism [PE]), with no significant differences in the incidences according to the type of arthroplasty [66].
•In a review of a national database, the rate of DVT and PE among over 4000 total shoulder arthroplasty surgeries was 0 and 0.20 percent, respectively [67]. Fracture surgery involving the proximal humerus was associated with slightly higher rates at 0.19 and 0.4 percent, respectively.
•For elbow arthroplasty, the mean incidence of VTE (four studies) was 0.49 percent [70]. The incidence for other elbow surgeries is similarly low [68,69].
•In a review of over 3000 consecutive upper extremity surgeries, one case of VTE occurred following carpal tunnel release and one following digit surgery [64].
In these and other studies, risk factors for VTE have included predominantly patient-specific factors such as older age, higher body mass index, prior history of DVT, family history of VTE and other medical comorbidities [64,66-68,71,73]. Procedure-related factors have included traumatic indication (particularly proximal humerus fracture), longer operative time (greater than 90 minutes), and revisional surgery.
●Efficacy pharmacologic thromboprophylaxis – Data reporting the effect of thromboprophylaxis in this population are limited to case series [70,74-77]. One small case series reported that aspirin did not significantly reduce VTE rates, likely because the event rate was so low [75]. Data to support aspirin in this population are indirect and limited to a subgroup of patients with polytrauma [30]. These data are discussed separately. (See "Venous thromboembolism risk and prevention in the severely injured trauma patient" and "Prevention of venous thromboembolism in adults undergoing hip fracture repair or hip or knee replacement", section on 'Aspirin'.)
ROLE FOR MECHANICAL THROMBOPROPHYLAXIS — There may be a role for mechanical thromboprophylaxis in patients undergoing non-major lower or upper extremity orthopedic procedures who are considered at high risk of VTE but who are also at high risk for bleeding or in whom anticoagulants are contraindicated.
When used, mechanical devices (ie, sequential compression devices) are placed on one (if the involved extremity has a contraindication) or both lower extremities, even for upper extremity procedures.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Superficial vein thrombosis, deep vein thrombosis, and pulmonary embolism" and "Society guideline links: Anticoagulation".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●The Basics topics (See "Patient education: Deep vein thrombosis (blood clot in the leg) (The Basics)" and "Patient education: Pulmonary embolism (blood clot in the lung) (The Basics)" and "Patient education: Choosing an oral medicine for blood clots (The Basics)" and "Patient education: Taking oral medicines for blood clots (The Basics)".)
●Beyond the Basics topics (see "Patient education: Deep vein thrombosis (DVT) (Beyond the Basics)" and "Patient education: Pulmonary embolism (Beyond the Basics)" and "Patient education: Warfarin (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Introduction – Non-major orthopedic surgery includes a variety of procedures involving the lower extremity (other than hip or knee arthroplasty, hip fracture repair, or severe trauma-related orthopedic surgery) or upper extremities. (See 'Types of non-major orthopedic extremity surgery' above.)
●Assessment of thrombotic and bleeding risk – For patients undergoing non-major orthopedic surgery, we assess the risk of postoperative venous thromboembolism (VTE) and bleeding risk to evaluate the need for and safety of pharmacologic thromboprophylaxis. (See 'General risk assessment' above.)
•In most patients, the baseline risk of VTE is generally low (eg, <2 percent risk of VTE in the first three months following surgery). However, we assess the risk as high when procedure-related factors are present (eg, prolonged immobilization or casting, surgeries known to be at high risk for VTE such as femoral fracture repair, Achilles tendon repair) or patient-specific factors exist (eg, previous VTE) (table 2). (See 'Risk of thrombosis' above.)
•The baseline bleeding risk in nontrauma patients undergoing non-major orthopedic surgery is also considered low (eg, <2 percent) (table 3). However, we consider that shoulder and some foot surgeries have a higher risk of bleeding (2 to 4 percent) and that patient-specific factors may augment the baseline risk (eg, patients on anticoagulants). (See 'Risk of bleeding' above.)
●Repair of isolated long bone above- and below-knee fracture/soft tissue injury
•For patients who undergo surgical repair of an isolated long bone above- or below-knee fracture/soft tissue injury that is considered at high risk of VTE, we suggest pharmacologic thromboprophylaxis rather than no prophylaxis, provided that the bleeding risk is low (Grade 2C). This includes femoral shaft fracture, femoral neck, inter- or subtrochanteric fracture, tibial plateau fracture, patellar fracture, realignment procedures such as tibial osteotomy, and/or surgery requiring prolonged immobilization or casting. (See 'Isolated long bone above- and below-knee fracture/soft tissue injury' above.)
•For all other patients, we suggest early and frequent ambulation with active joint range of motion rather than pharmacologic thromboprophylaxis (Grade 2C), unless patient-specific factors that place the individual at high risk for VTE are present (eg, active cancer, thrombophilia, multiple risk factors present, previous or family history of VTE) (table 2).
•When thromboprophylaxis is chosen, we suggest low molecular weight (LMW) heparin or rivaroxaban (Grade 2C). However, the optimal agent is unknown, and practice varies widely. Aspirin is frequently administered in this population, particularly in individuals with low thrombotic risk who are not yet weight-bearing, but data to support it are indirect.
•Prophylaxis is generally administered for the period of immobilization (Grade 2C).
•This approach is based upon evidence that has consistently demonstrated that the risk of VTE is wide in this population (<1 to 6 percent), suggesting that select patients on the higher end of this risk range may benefit from pharmacologic thromboprophylaxis, while thromboprophylaxis may not be justified for those on the lower end of this risk. For those in whom pharmacologic thromboprophylaxis is administered, data suggest that thromboprophylaxis may impact VTE rates by preventing asymptomatic or distal deep vein thrombosis rather than symptomatic disease (ie, VTE that is clinically significant and at risk of embolization). (See 'Efficacy of pharmacologic prophylaxis' above and 'Venous thromboembolism risk' above.)
●Knee or hip arthroscopic surgery, foot and ankle surgery, upper extremity surgery – Patients undergoing knee or hip arthroscopic surgery, foot and ankle surgery, or upper extremity surgery do not typically require pharmacologic thromboprophylaxis, since the risk of VTE is very low in these populations. However, in patients assessed as having a higher than usual procedural risk (eg, prolonged immobilization expected, Achilles tendon repair, proximal humerus fracture) or patient-specific factors (eg, prior VTE, active cancer, thrombophilia, multiple risk factors present, family history of VTE), pharmacologic prophylaxis is reasonable. While the optimal agent is unknown, LMW heparin is appropriate, although aspirin is frequently administered in those considered to have low thrombotic risk. (See 'Knee arthroscopic surgery' above and 'Foot and ankle surgery' above and 'Upper extremity procedures' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Menaka Pai, MD, FRCPC, who contributed to earlier versions of this topic review.
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