American Academy of Orthopaedic Surgeons Clinical Practice Guideline on: Prevention of Symptomatic Pulmonary Embolism in Patients Undergoing Total Hip or Knee Arthroplasty

Johanson, Norman A. MD; Lachiewicz, Paul F. MD; Lieberman, Jay R. MD; Lotke, Paul A. MD; Parvizi, Javad MD; Pellegrini, Vincent MD; Stringer, Theodore A. MD; Tornetta, Paul III MD; Haralson, Robert H. III MD, MBA; Watters, William C. III MD

Journal of Bone & Joint Surgery - American Volume:
doi: 10.2106/JBJS.I.00511
Evidence-Based Orthopaedics

    The following recommendations are based on a systematic review of the literature and are evidence-based

    Recommendation 3.3 Chemoprophylaxis of patients undergoing hip or knee replacement

    Recommendation 3.3.1 Patients at standard risk of both PE and major bleeding should be considered for one of the chemoprophylactic agents evaluated in this guideline, including-in alphabetical order: Aspirin, LMWH, synthetic pentasaccharides, and warfarin. (Level III, Grade B (choice of prophylactic agent), Grade C (dosage and timing))Note: The grade of recommendation was reduced from B to C for dosage and timing because of the lack of consistent evidence in the literature defining a clearly superior regime.

    Recommendation 3.3.2 Patients at elevated (above standard) risk of PE and at standard risk of major bleeding should be considered for one of the chemoprophylactic agents evaluated in this guideline, including-in alphabetical order: LMWH, synthetic pentasaccharides, and warfarin. (Level III, Grade B (choice of prophylactic agent), Grade C (dosage and timing)).Note: The grade of recommendation was reduced from B to C for dosage and timing because of the lack of consistent evidence in the literature on risk stratification of patient populations.

    Recommendation 3.3.3 Patients at standard risk of PE and at elevated (above standard) risk of major bleeding should be considered for one of the chemoprophylactic agents evaluated in this guideline, including-in alphabetical order: Aspirin, Warfarin, or none. (Level III, Grade C)Note: The grade of recommendation was reduced from B to C for dosage and timing because of the lack of consistent evidence in the literature on risk stratification of patient populations.

    Recommendation 3.3.4 Patients at elevated (above standard) risk of both PE and major bleeding should be considered for one of the chemoprophylactic agents evaluated in this guideline, including-in alphabetical order: Aspirin, Warfarin, or none. (Level III, Grade C)Note: The grade of recommendation was reduced from B to C for dosage and timing because of the lack of consistent evidence in the literature on risk stratification of patient populations. No studies currently include patients at elevated risk of major bleeding and/or PE in study groups.

    The following additional recommendations are based on the results of the objective AAOS Consensus Process in which the work group members participated.

    Recommendation 1.1 All patients should be assessed pre-operatively for elevated risk (greater than standard risk) of pulmonary embolism. (Level III, Grade B)

    Recommendation 1.2 All patients should be assessed pre-operatively for elevated risk (greater than standard risk) of major bleeding. (Level III, Grade C)Note: Grade of Recommendation reduced because of lack of consistent evidence on risk stratification of patient populations.

    Recommendation 1.3 Patients with known contraindications to anticoagulation should be considered for vena cava filter replacement. (Level V, Grade C)

    Recommendation 2.1 Patients should be considered for intra-operative and/or immediate postoperative mechanical prophylaxis. (Level III, Grade B)

    Recommendation 2.2 In consultation with the anesthesiologist, patients should be considered for regional anesthesia. (Level IV, Grade C)

    Recommendation 3.1 Post-operatively, patients should be considered for continued mechanical prophylaxis until discharge to home. (Level IV, Grade C)

    Recommendation 3.2 Post-operatively, patients should be mobilized as soon as feasible to the full extent of medical safety and comfort. (Level V, Grade C)

    Recommendation 3.4 Routine screening for DVT or PE post-operatively in asymptomatic patients is not recommended. (Level III, Grade B)

    Recommendation 4.1 Patients should be encouraged to progressively increase mobility after discharge to home. (Level V, Grade C)

    Recommendation 4.2 Patients should be educated about the common symptoms of deep venous thrombosis and pulmonary embolism. (Level V, Grade B)Note: The level of evidence is level V, expert opinion, but the strength of recommendation is B rather than C because patient education is consistent with the minimal expected standard of care for today's medical practices.

    Of the fourteen recommendations listed above, only recommendations 3.3.1, 3.3.2, 3.3.3 and 3.3.4 are based on the systematic review of the literature conducted between August 2006 and March 2007 by The Center for Clinical Evidence Synthesis at Tufts New England Medical Center. The other recommendations contained in this guideline are based on consensus development methods only.

    Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors, or a member of his or her immediate family, received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (DePuy, Bayer Pharm, Stryker, Covidien, Ortho-McNeil, Intrinsic Therapeutics, Blackstone Medical), and one or more of the authors, or a member of his or her immediate family, received, in any one year, payments or other benefits of less than $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Covidien, DJO Global, Johnson and Johnson).

    Disclaimer: This clinical guideline was developed by an AAOS physician volunteer Work Group and is provided as an educational tool based on an assessment of the current scientific and clinical information and accepted approaches to treatment. It is not intended to be a fixed protocol as some patients may require more or less treatment. Patient care and treatment should always be based on a clinician's independent medical judgment given the individual clinical circumstances.

    Copyright 2009 by The Journal of Bone and Joint Surgery, Incorporated