Routine Chemoprophylaxis for Venous Thromboembolism in Orthopedic Patients: Is it Justified?

Introduction: Orthopedic patients require prolonged immobilization and undergo major surgical procedures which make them susceptible to venous thromboembolism (VTE). The role of chemoprophylaxis to prevent VTE is still debated, with many surgeons using it routinely, while certain centers use it sporadically. The present review assesses the evidence in literature regarding the VTE chemoprophylaxis in different subsets of orthopedic patients with specific focus on arthroplasty, pelvic trauma, and long-bone fractures. Materials and methods: A PubMed search to look for current usage of routine chemoprophylaxis in hip/knee arthroplasties and postoperative cases of pelvic-acetabular, hip, and tibia fractures yielded 2,216 hits. Based on the relevant articles, the evidence in literature was studied to determine the role of chemoprophylaxis. Results: The incidence of VTE in orthopedics patients is well documented with several studies, both Indian and Western quoting rates of up to 72%. There are no guidelines from any Indian orthopedics body or society, and most of the surgeons rely on the recommendations from the American Academy of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP). These guidelines are based on the review of the literature and recommend routine chemoprophylaxis to prevent VTE in hip/knee arthroplasties and hip fractures. Low molecular weight heparin, apixaban, rivaroxaban, and fondaparinux are potential agents. Oral low-dose aspirin is also effective in arthroplasty patients, while its efficacy may not be at par with the other agents in trauma cases; the evidence is however still not clear. There is no similar role of routine chemoprophylaxis in fractures distal to the knee; as the thrombi formed are distal, they do not often embolize to the lungs and are rarely clinically significant. Conclusion: Patients undergoing hip and knee arthroplasties or surgeries for pelvic-acetabular and hip fractures require routine VTE chemoprophylaxis. LMWH or newer agents like apixaban or fondaparinux are effective in decreasing the incidence of clinical VTE and could be prescribed for a period as long as 6-8 weeks postoperatively.