Orthopedic Surgery and Venous

Thrombosis
 Venothromboembolism:
Orthopedic Surgery
 Compared to other surgical interventions,
patients undergoing major orthopedic joint
reconstructive procedures have one of the
highest rates of thromboembolic disease.
 Without adequate mechanical or
anticoagulation prophylaxis, 50% to 80%
of total hip and knee arthoplasties will
develop deep venous thrombosis (DVT).
 Venothromboembolism:
Orthopedic Surgery (cont’d)
 Total pulmonary embolism (PE) rates for
hip arthroplasty ranges between 0.9 to
28% (fatal PE 0.1-2.0%); total PE rates for
knee arthroplasty ranges between 1.5 to 10
(fatal PE 0.1-1.7%).
 With pre-and post-operative
anticoagulation regimens commonly used in
these patients, the incidence of DVT has
been reduced to 12-15%.
Incidence of VTE Within 91 Days of Surgery
Among Patients Without a Malignancy

Surgical procedure % total 95% CI

Total hip arthroplasty 2.4 2.3-2.5

Total knee arthroplasty 1.7 1.7-1.8
ORIF femur 1.9 1.8-2.0
Shoulder arthroplasty 0.5 0.3-0.8
Thyroid surgery 0.2 0.1-0.4
Open cholecystectomy 0.5 0.4-0.6
Nephrectomy 0.4 0.2-0.6
Total abdominal 0.3 0.2-0.3
hysterectomy
Replacement of the heart 0.5 0.5-0.6
valve

White R et al, Thromb Heamost 2003, 90:446

 Incidence DVT in Total Hip
Arthroplasty

He Xing K. et al, Thrombosis Research, 2008, 123:24–34

Thrombotic Stimuli During Total Hip
and Knee Arthoplasty

 Venous stasis: Tourniquet

placement, immobility during
the postoperative period
 Endothelial injury:
Manipulation during preparation
of the femoral prosthesis
releases tissue thromboplastin
and other thrombogenic
molecules
 Hypercoaguability:
Thrombogenic stimuli -
reduction in antithrombin III
and inhibition of fibrinolysis due
to blood loss
 Unexplained Factors for VTE in
Orthopedic Surgery

 Hypothesis
 Bone contains a large concentration of
phospholipids, which are found as structural
components of fat and hematopoietic cells
that comprise the bone marrow (hidden
epitopes).
 Disruption or invasion of this site as a
consequence of surgery causes inflammation
and cellular apoptosis leading to turnover of
phospholipid membranes.
Tourniquets

 Opinions differ as to the pressure required in

tourniquets to prevent bleeding (usually 100
mm Hg above patient's systolic blood
pressure for the leg and 50 mm Hg above
systolic blood pressure for the arm). Before
the tourniquet is inflated, the limb should be
elevated for about 1 minute and tightly
wrapped with an elastic bandage distally to
proximally. Oozing despite tourniquet
inflation is most likely caused by
intramedullary blood flow in long bones.

07/27/21 8
  The duration of safe tourniquet inflation
is unknown (1–2 hours is not associated
with irreversible changes). Five minutes
of intermittent perfusion between 1 and
2 hours may allow more extended use.
 Transient systemic metabolic acidosis
and increased PaCO2 (1–8 mm Hg) may
occur after tourniquet deflation.

07/27/21 9
  Tourniquet pain despite adequate
operative anesthesia typically appears
after about 45 minutes (may reflect
more rapid recovery of C fibers as the
block wanes). During surgery, this pain
is managed with opioids and hypnotics

07/27/21 10
Fat Embolus Syndrome

 Patients at risk include those with

multiple traumatic injuries and surgery
involving long bone fractures,
intramedullary instrumentation or
cementing, or total knee surgery. The
incidence of fat embolism syndrome in
isolated long bone fractures is 3% to
4%, and the mortality rate is 10% to
20%.

07/27/21 11
  Clinical and laboratory signs usually
occur 12 to 40 hours after injury and
may range from mild dyspnea to coma .
 Treatment includes early stabilization of
fractures and support of oxygenation.
Steroid therapy may be instituted

07/27/21 12
Criteria for Diagnosis of Fat
Embolism Syndrome
 MAJOR :
1. Axillary or subconjunctival petechiae
2. Hypoxemia (PaO2< 60 mm Hg)
3. CNS depression (disproportionate to
hypoxemia)
4. Pulmonary edema

07/27/21 13
Criteria for Diagnosis of Fat
Embolism Syndrome
 MINOR:
Tachycardia (>100 bpm)
1.Hyperthermia
Retinal fat emboli
1.Urinary fat globules
2.Decreased platelets
3.Increased ESR
4.DIC

07/27/21 14
Methyl Methacrylate

 Insertion of this cement may be associated

with hypotension, which has been attributed
to absorption of the volatile monomer of
methyl methacrylate or embolization of air
(nitrous oxide should be discontinued before
cement is placed) and bone marrow during
femoral reaming.

07/27/21 15
 Adequate hydration and maximizing
oxygenation minimize the hypotension and
arterial hypoxemia that may accompany
cementing of the prosthesis.

07/27/21 16
 Venous thromboembolism is a major
cause of death after surgery or
trauma to the lower extremities.
Without prophylaxis, 40% to 80% of
orthopaedic patients develop venous
thrombosis. (The incidence of fatal
pulmonary embolism is highest in
patients who have undergone surgery
for hip fracture.)
07/27/21 17
 Antithrombotic prophylaxis is based
on identification of risk factors .

07/27/21 18
Antithrombotic Regimens to Prevent Thromboembolism in
Orthopedic Surgical Patients

 Hip and Knee Arthroplasty and Hip Fracture Surgery

 LMWH* started 12 hours before surgery or 12 to 24 hours after
surgery or 4 to 6 hours after surgery at half the usual dose and
then increasing to the usual high-risk dose the following day.
 Fondaparinux (2.5 mg started 6 to 8 hours after surgery)

 Adjusted-dose warfarin started preoperatively or the evening

after surgery (INR target, 2.5; range, 2.0–3.0)

 Intermittent pneumatic compression is an alternative option to

anticoagulant prophylaxis in patients undergoing total knee
(but not hip) replacement.

07/27/21
 Spinal Cord Injury

 LMWH after primary hemostasis is evident

 Intermittent pneumatic compression is an

alternative when anticoagulation is contraindicated
early after surgery.

 During the rehabilitation phase, conversion to

adjusted-dose warfarin (INR target, 2.5; range,
2.0–3.0).

07/27/21 20
 Elective Spine Surgery

 Routine use of thromboprophylaxis, apart from

early and persistent mobilization, is not
recommended.

 Knee Arthroscopy

 Routine use of thromboprophylaxis, apart from

early and persistent mobilization, is not
recommended.
07/27/21 21
 Several studies show a decreased
incidence of deep vein thrombosis
(DVT) and pulmonary embolism in
patients undergoing hip surgery and
knee surgery under epidural and
spinal anesthesia .

07/27/21 22
Possible Explanations for Decreased Incidence of Deep Vein
Thrombosis in Patients Receiving Regional Anesthesia

 Rheologic changes resulting in hyperkinetic lower

extremity blood flow and associated decrease in
venous stasis and thrombus formation
 Beneficial circulatory effects from epinephrine
added to local anesthetic solution
 Altered coagulation and fibrinolytic responses to
surgery under neural blockade, resulting in
decreased tendency for blood to clot
 Absence of positive pressure ventilation and its
effects on circulation
 Direct local anesthetic effects (decreased platelet
aggregation)

07/27/21 23
 Despite perceived advantages of neuraxial
techniques for hip and knee surgery
(including a decreased incidence of DVT),
patients receiving perioperative
anticoagulants and antiplatelet medications
are often not considered candidates for
spinal or epidural anesthesia because of the
risk of neurologic deficit from a spinal or
epidural hematoma .

07/27/21 24
Neuraxial Anesthesia and Analgesia in Orthopedic
Patients Receiving Antithrombotic Therapy

 Low-Molecular-Weight Heparin
 Needle placement should occur 10 to 12 hours
after a dose.
 Indwelling neuraxial catheters are allowed with
once-
daily (but not twice-daily) dosing of LMWH.
 It is optimal to place and remove indwelling
catheters in the morning and administer LMWH in
the evening to allow normalization of hemostasis
to occur before catheter manipulation.

07/27/21 25
Warfarin
 Adequate levels of all vitamin K–dependent
factors should be present during catheter
placement and removal.
 Patients chronically on warfarin should have a
normal INR before performance of the regional
technique.
 PT and INR should be monitored daily.
 The catheter should be removed when INR
<1.5.

07/27/21 26
Fondaparinux
 Neuraxial techniques are not advised
in patients who are anticipated to
receive fondaparinux.
.

07/27/21 27
Nonsteroidal Anti-Inflammatory
Drugs
 No significant risk of regional anesthesia-
related
bleeding is associated with aspirin-type drugs.
 For patients receiving warfarin or LMWH, the
combined anticoagulant and antiplatelet effects
may increase the risk of perioperative bleeding.
 Other medications affecting platelet function
(thienopyridine derivatives and glycoprotein
IIb/IIIa platelet receptor inhibitors) should be
avoided.

07/27/21 28
 The patient should be closely monitored in
the perioperative period for signs of
paralysis. If a spinal hematoma is
suspected, the treatment is immediate
decompressive laminectomy. (Recovery of
neurologic function is unlikely if >10–12
hours elapse.)

07/27/21 29
Thank you