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Thromboprophylaxis in Orthopaedic Surgery

NICE guideline [NG 89] Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism. Last updated Aug 2019.

Guidelines

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, intermitten pneumatic compression can be offered as an alternative
 

Anti-embolism stocking is passive and static, providing constant graded compression to improve venous return.

Intermittent pneumatic compression devices provies active periodic compression (cyclic inflation and deflation) to mimic the calf 'muscle pump'.

NICE outlined different recommendations depending on the type of orthopaedic surgeries.
 

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.

 

LMWHLow molecular weight heparin is delayed 6-12 hours (or 6 hours if fondaparinux) after surgery to allow adequate surgical haemostasis and minimise bleeding / haematoma formation in the wound. 

Offer VTEVenous thromboembolism prophylaxis to ALL patients.

1st line:
  • LMWHLow molecular weight heparin for 10 days followed by aspirin 75mg / 150mg for 28 days, OR
  • LMWHLow molecular weight heparin for 28 days + anti-embolism stockings until discharge, OR
  • Rivaroxaban 6-10 hours after surgery for 5 weeks
 

Although not specificed by NICE, the BNF recommend starting LMWHLow molecular weight heparin 12-24 hours after survery.


2nd line: apixaban or dabigatran

3rd line: anti-embolism stockings

Offer VTEVenous thromboembolism prophylaxis to ALL patients.

1st line:
  • Aspirin 75mg / 150mg for 14 days, OR
  • LMWHLow molecular weight heparin for 28 days + anti-embolism stockings until discharge, OR
  • Rivaroxaban 6-10 hours after surgery for 5 weeks
 

Although not specificed by NICE, the BNF recommend starting LMWHLow molecular weight heparin 12-24 hours after survery.


2nd line: apixaban or dabigatran

3rd line: intermittent pneumatic compression

VTEVenous thromboembolism prophylaxis only indicated if:
  • High risk of VTE, AND
  • Total anaesthesia time >90 min

VTE prophylaxis of choice: LMWHLow molecular weight heparin 6-12 hours after surgery for 14 days

VTEVenous thromboembolism prophylaxis generally not needed.

Consider VTEVenous thromboembolism prophylaxis if:
  • Patient requires immobilisation, OR
  • Total anaesthesia time >90 min, OR
  • Patient's risk of VTEVenous thromboembolism outweight risk of bleeding

VTEVenous thromboembolism prophylaxis generally not needed.

Consider VTEVenous thromboembolism prophylaxis if:
  • Patient requires immobilisation, OR
  • Total anaesthesia time >90 min

NICE recommends choosing either LMWHLow molecular weight heparin or UFHUnfractionated heparin.

BNF treatment summary says that UFHUnfractionated heparin is the preferred thromboprophylaxis agent in renal impairment.

References

Author: Adams Lau
Reviewer:
Last edited: 10/05/25