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Venous Thromboembolism Prophylaxis in Orthopedic Surgery

Slide: 9 of 30

Baseline Postoperative Risks of VTE Outcomes in the Absence of Pharmacological Prophylaxis

This slide summarizes the baseline postoperative risks of venous thromboembolic outcomes and bleeding outcomes in the absence of pharmacological prophylaxis in contemporary practice (trials and studies conducted from 1980 to the present). To determine the impact of surgery on venous thromboembolism (VTE), pulmonary embolism (PE), or deep vein thrombosis (DVT), we only allowed trial arms where no prophylaxis was given (either control or placebo); however, for bleeding outcomes, trial arms with mechanical prophylaxis were allowed because the risk of bleeding is not impacted by these methods. The majority of trials did not specifically define the duration of followup and implied an immediate postoperative followup; therefore, the period for which these incidences reflect is likely the immediate postoperative period rather than longer term.

Most of the literature evaluated total hip replacement (THR) and total knee replacement (TKR) surgeries with very little evaluation of hip fracture surgery. Therefore, all outcomes evaluated for hip fracture surgery were rated with insufficient evidence. As randomization was broken to pool data from placebo and control arms, the risk of bias was inherently higher. Although each major orthopedic surgery was considered separately, high statistical heterogeneity was observed between trials for most end points, which likely reflect the different time periods of followup, the countries and ethnicities where the trials were conducted, and when or how rigorously the end points were assessed for. In THR surgery, there was moderate strength of evidence for the incidence of major bleeding, although the strength of evidence was low for incidence of PE, DVT, proximal DVT, distal DVT, and minor bleeding. In THR surgery, the strength of evidence was moderate for the incidence of minor bleeding while low for the incidences of PE, DVT, proximal DVT, distal DVT, and major bleeding. For all outcomes evaluated in hip fracture surgery, data were insufficient; whereas, THR and TKR surgery data were insufficient for symptomatic, objectively confirmed VTE, major venous thromboembolism, fatal or nonfatal PE, asymptomatic or symptomatic DVT, major bleeding leading to reoperation, surgical site bleeding, and bleeding leading to infection or to transfusion in either THR or TKR surgery.