Thromboprophylaxis in Orthopaedic Surgery

Contraindications outlined by NICE:

• Peripheral arterial disease
• Peripheral arterial bypass grafting
• Peripheral neuropathy or other causes of sensory impairment
• Severe leg oedema
• Major limb deformity or unusual leg size or shape preventing correct fit
• Any local conditions in which anti-embolism stockings may cause damage – for example, fragile 'tissue paper' skin, dermatitis, gangrene or recent skin graft
• Known allergy to material of manufacture

NICE recommendations:

• Use anti-embolism stockings that provide graduated compression and produce a calf pressure of 14-15 mmHg

• Measure the person's leg size and offer the correct size of stocking
• Encourage the person to wear it day and night until they no longer have significantly reduced mobility
• Remove anti-embolism stockings daily for hygiene purposes and to inspect skin condition.
  • In people with a significant reduction in mobility, poor skin integrity or any sensory loss, inspect the skin 2 or 3 times a day, particularly over the heels and bony prominences
• Stop the use of anti-embolism stockings if there is marking, blistering or discolouration of the skin, particularly over the heels and bony prominences, or if the person experiences pain or discomfort
  • If suitable, intermittent pneumatic compression can be offered as an alternative

Definition: any clinical decision taken to manage the affected limb in a way that would prevent normal weight-bearing status or use of that limb, or both.

Consider LMWH or fondaparinux sodium if VTEVenous thromboembolism risk outweighs risk of bleeding.

Offer VTEVenous thromboembolism prophylaxis to ALL patients.

1st line:

• LMWHLow molecular weight heparin 6-12 hours after surgery, OR
• Fondaparinux 6 hours after surgery

If the surgery is delayed beyond the day after admission → offer pre-operative thromboprophylaxis (LMWHLow molecular weight heparin or fondaparinux)

• LMWHLow molecular weight heparin last dose no less than 12 hours before surgery
• Fondaparinux last dose no less than 24 hours before surgery

If pharmacological prophylaxis is not appropriate → consider intermittent pneumatic compression.

VTEVenous thromboembolism prophylaxis is generally not needed.

Consider VTEVenous thromboembolism prophylaxis if:

• Patient requires immobilisation, OR
• Total anaesthesia time >90 min, OR
• Patient's risk of VTEVenous thromboembolism outweighs risk of bleeding

VTEVenous thromboembolism prophylaxis is generally not needed.

Consider VTEVenous thromboembolism prophylaxis if:

• Patient requires immobilisation, OR
• Total anaesthesia time >90 min