Overview
Venous thromboembolism (VTE) includes deep-vein thrombosis (DVT) and pulmonary embolism (PE). Major orthopaedic trauma, lower-limb immobilisation and arthroplasty increase risk because of venous stasis, endothelial injury and hypercoagulability.
Risk factors
Important factors include:
- Previous VTE
- Major lower-limb or pelvic surgery
- Hip fracture
- Prolonged immobility
- Active malignancy
- Increasing age
- Obesity
- Thrombophilia
- Oestrogen therapy
- Major trauma
Clinical features
DVT
- Unilateral swelling
- Calf or thigh pain
- Pitting oedema
- Increased limb circumference
Clinical features alone are insufficient to confirm or exclude DVT.
Pulmonary embolism
- Unexplained dyspnoea
- Pleuritic chest pain
- Tachycardia
- Hypoxia
- Syncope or haemodynamic collapse in severe PE
Investigation
Investigation should follow a validated diagnostic pathway based on pre-test probability.
- Compression ultrasonography is the principal investigation for suspected proximal DVT.
- CT pulmonary angiography is commonly used for suspected PE when imaging is indicated.
- D-dimer is useful mainly when clinical probability is low or intermediate; it is often nonspecific after trauma or surgery.
Prevention in orthopaedics
Prevention combines assessment of VTE risk and bleeding risk.
Mechanical measures
- Early mobilisation
- Intermittent pneumatic compression where appropriate
- Graduated compression stockings in selected patients
Pharmacological prophylaxis
Depending on the procedure and patient, options include low-molecular-weight heparin, direct oral anticoagulants, fondaparinux or aspirin in selected pathways. The agent and duration should follow local or national guidance.
Important principles
- Major joint replacement and hip fracture surgery are high-risk settings.
- Prophylaxis must be individualised when bleeding risk is high.
- A confirmed VTE requires therapeutic anticoagulation unless contraindicated.
References
- Orthobullets. Deep Vein Thrombosis and perioperative VTE topics.
- NICE. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing.