Orthopaedic surgery - elective hip replacement, elective knee replacement and hip fracture and reduction of risk of venous thromboembolism (VTE)

NICE have issued some specific advice regarding orthopaedic surgery (elective hip replacement, elective knee replacement and hip fracture) and reduction of risk of DVT/PE (1,2)

• the summaries of product characteristics state postoperative start times for dabigatran, rivaroxaban and fondaparinux, and preoperative start times for most LMWHs - the relevant SPCs and the full NICE guideline (2) should be consulted before prescribing
  
  
  • lower limb immobilisation
    • consider pharmacological VTE prophylaxis with LMWH or fondaparinux sodium for people with lower limb immobilisation whose risk of VTE outweighs their risk of bleeding. Consider stopping prophylaxis if lower limb immobilisation continues beyond 42 days (2)
      
      
  • Elective hip replacement Elective knee replacement
    • offer VTE prophylaxis to people undergoing elective hip replacement surgery whose risk of VTE outweighs their risk of bleeding. Choose any one of:
      • LMWH for 10 days followed by aspirin (75 or 150 mg) for a further 28 days
      • LMWH for 28 days combined with anti-embolism stockings (until discharge)
      • rivaroxaban, within its marketing authorisation, is recommended as an option for the prevention of venous thromboembolism in adults having elective total hip replacement surgery or elective total knee replacement surgery
    • consider one of the following if none of the options can be used:
      • apixaban is recommended as an option for the prevention of venous thromboembolism in adults after elective hip or knee replacement surgery
      • dabigatran etexilate within its marketing authorisation, is recommended as an option for the primary prevention of venous thromboembolic events in adults who have undergone elective total hip replacement surgery or elective total knee replacement surgery
    • consider anti-embolism stockings until discharge from hospital if pharmacological interventions are contraindicated in people undergoing elective hip replacement surgery
      
      
    • offer VTE prophylaxis to people undergoing elective knee replacement surgery whose VTE risk outweighs their risk of bleeding. Choose any one of:
      • aspirin (75 or 150 mg) for 14 days
      • LMWH for 14 days combined with anti-embolism stockings until discharge
      • rivaroxaban within its marketing authorisation, is recommended as an option for the prevention of venous thromboembolism in adults having elective total hip replacement surgery or elective total knee replacement surgery
    • consider one of the following if none of the options can be used:
      • apixaban
      • dabigatran etexilate
    • consider intermittent pneumatic compression if pharmacological prophylaxis is contraindicated in people undergoing elective knee replacement surgery. Continue until the person is mobile
      
      
  • fragility fractures of the pelvis, hip and proximal femur
    • offer VTE prophylaxis for a month to people with fragility fractures of the pelvis, hip or proximal femur if the risk of VTE outweighs the risk of bleeding. Choose either:
      • LMWH, starting 6-12 hours after surgery or
      • fondaparinux sodium, starting 6 hours after surgery, providing there is low risk of bleeding
    • consider pre-operative VTE prophylaxis for people with fragility fractures of the pelvis, hip or proximal femur if surgery is delayed beyond the day after admission. Give the last dose no less than 12 hours before surgery for LMWH or 24 hours before surgery for fondaparinux sodium
    • consider intermittent pneumatic compression for people with fragility fractures of the pelvis, hip or proximal femur at the time of admission if pharmacological prophylaxis is contraindicated. Continue until the person no longer has significantly reduced mobility relative to their normal or anticipated mobility

Reference:

• 1) NICE (January 2010). Reducing the risk of venous thromboembolism
• 2) NICE (March 2018). Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism