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(Chest. 2005;128:3364-3371.)
© 2005 American College of Chest Physicians

Identifying Orthopedic Patients at High Risk for Venous Thromboembolism Despite Thromboprophylaxis*

Renée L. Schiff, MD; Susan R. Kahn, MD, MSc; Ian Shrier, MD, PhD; Carla Strulovitch, RN; Wahbi Hammouda, MD; Eva Cohen, BPharm, DPH and David Zukor, MD

* Department of Medicine (Drs. Schiff and Kahn), McGill University; and Center for Clinical Epidemiology and Community Studies (Dr. Kahn, Dr. Shrier, and Ms. Strulovitch), Division of Orthopedic Surgery (Dr. Zukor), Division of Hematology (Dr. Hammouda), and Department of Pharmacy (Ms. Cohen), SMBD Jewish General Hospital, Montreal, QC, Canada.

Correspondence to: Susan R. Kahn, MD, MSc, Center for Clinical Epidemiology and Community Studies, Sir Mortimer B. Davis Jewish General Hospital, 3755 Cote Ste. Catherine Rm. A-127, Montreal, Quebec H3T 1E2; e-mail: susan.kahn{at}mcgill.ca

Objective: To evaluate risk factors for venous thromboembolism (VTE) despite thromboprophylaxis in major orthopedic surgery patients at a tertiary care hospital.

Methods: Charts from consecutive patients who underwent total hip replacement (THR), total knee replacement (TKR), or hip fracture surgery (HFS) [hip pinning or hemiarthroplasty] from August 1, 1999, to April 30, 2000, at a large Canadian teaching hospital were abstracted using standardized case report forms. Data were collected on patient characteristics, surgical characteristics, and thromboprophylaxis regimen. Results of tests performed for suspected VTE were documented. Associations between characteristics of interest and objectively confirmed VTE were examined in multivariate analysis.

Results: Over the study period, 310 patients underwent major orthopedic surgery and received standard thromboprophylaxis with either dalteparin or enoxaparin (mean duration of prophylaxis, 7 days). Of these, 34% underwent THR, 30% underwent TKR, and 36% underwent HFS. Of 83 suspected cases of VTE, 44 cases (7 proximal and 37 distal deep venous thrombosis [DVT]); 14% of study population) were confirmed with objective testing. Multivariate analyses revealed that knee surgery (odds ratio [OR], 4.8; 95% confidence interval [CI], 2.3 to 10.1) and type of low molecular weight heparin (LMWH) [enoxaparin (more protective): OR, 0.39; 95% CI, 0.20 to 0.80] independently predicted VTE. No patient characteristics (including previous VTE, malignancy, hormonal therapy, postoperative complications) were associated with VTE.

Conclusion: Despite standard thromboprophylaxis, symptomatic breakthrough VTE, primarily distal DVT, developed in 14% of patients undergoing major orthopedic surgery. Factors that independently predicted VTE in our population were TKR surgery and type of LMWH. TKR patients may warrant more aggressive postoperative physiotherapy and ambulation and adjunctive prophylactic measures such as pneumatic compression. Due to the heterogeneity of different LMWH compounds, direct comparison of the effectiveness of enoxaparin with dalteparin for orthopedic prophylaxis in prospective, randomized trials seems warranted.

Key Words: deep venous thrombosis • low-molecular-weight heparin • orthopedic surgery • thromboprophylaxis • venous thromboembolism






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Copyright © 2005 by the American College of Chest Physicians.