New Canadian guidance for prevention of VTE following orthopedic surgery

Without thromboprophylaxis, venous thromboembolism (VTE) occurs in up to 60% of patients following orthopedic surgery. It presents as deep vein thrombosis and/or pulmonary embolism and is a potentially preventable cause of morbidity and mortality. Thrombosis Canada recently issued new guidance on thromboprophylaxis after orthopedic surgery.1,2 The guidance documents provide a practical approach to the prevention of venous thromboembolism (VTE) in various patient groups undergoing orthopedic surgery or with lower extremity fractures. A collaborative approach among physicians, nurses, pharmacists, and respiratory, occupational and rehabilitation therapists is encouraged to reduce or prevent VTE and its potentially serious consequences.The guidelines address risk stratification, with an assessment of risk factors for VTE associated with orthopedic surgery, including patient factors, medical conditions, medications (e.g., oral contraceptives, some medications used to treat cancer) and procedure-specific factors. The most critical period for VTE development occurs within the first month after orthopedic surgery, but the risk may persist for longer.A bleeding assessment should also be performed. Risk factors for bleeding associated with orthopedic surgery are tabulated in the guidelines. Pharmacologic thromboprophylaxis primarily includes acetylsalicylic acid (ASA), direct oral anticoagulants (DOACs) and low molecular weight heparin (LMWH). Choices should be individualized in collaboration with patients as some patients may prefer oral over injectable options or once- over twice-daily dosing. Some heparin-based medications have animal origins, which may be of concern to some patients because of religious or cultural beliefs.A table in the document summarizes suggested pharmacologic thromboprophylaxis regimens in orthopedic surgery patients, with preferred options, dosage regimens and duration of therapy outlined for hip or knee arthroplasty, hip fracture surgery, major orthopedic trauma, spine surgery, knee arthroscopy and other conditions.For most elective orthopedic surgery patients in whom thromboprophylaxis is recommended, anticoagulant prophylaxis should start approximately 12 hours after surgery (usually the morning after surgery). For hip fracture patients in whom surgery may be delayed, starting thromboprophylaxis shortly after admission is suggested. Although the optimal duration of thromboprophylaxis is not known for any orthopedic surgery group, extended prophylaxis for 14–35 days is recommended for patients undergoing hip and knee arthroplasty or hip fracture surgery. Most orthopedic surgery patients who go to rehabilitation should continue thromboprophylaxis at least until they are discharged from rehabilitation.While pharmacologic options, including DOACs and LMWHs, remain the mainstay of VTE prophylaxis, mechanical interventions such as intermittent pneumatic compression and graduated compression stockings serve as valuable adjuncts, particularly for high-risk patients or those with contraindications to anticoagulation. Mechanical thromboprophylaxis techniques are discussed in the guidelines, with recommendations on their safe and effective use. Overall, the guideline authors encourage a multidisciplinary approach to optimize patient outcomes, by incorporating early mobilization, standardized institutional protocols and ongoing education for healthcare providers. They encourage future research focusing on refining risk stratification tools and evaluating the long-term effectiveness of various thromboprophylaxis strategies to further reduce the burden of VTE in orthopedic surgery.References:Thrombosis Canada. Thromboprophylaxis: orthopedic surgery. (accessed August 5, 2025).Carrier M, Chamberlain L, Parvizi J. Orthopedic surgery VTE thromboprophylaxis: guidelines summary. (accessed August 5, 2025).

New Canadian guidance for prevention of VTE following orthopedic surgery

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