Chapter 12 Coagulation, Thromboembolism, and Blood Management in Orthopaedic Surgery

Venous thromboembolic disease and prophylaxis are subjects of controversy in orthopaedic surgery. Venous thromboembolism is a major risk in patients undergoing total hip and knee arthroplasty as well as repair of a hip fracture. In addition, patients sustaining major orthopaedic trauma including spinal cord injury as well as patients undergoing treatment of various other musculoskeletal conditions are at potential risk for thromboembolism. Morbidity and mortality are associated with both thromboembolic disease and prophylaxis. Various forms of pharmacologic and mechanical prophylaxis are available and are presented in the American Academy of Orthopaedic Surgeons’ guideline on prevention of pulmonary embolism.1 This clinical practice guideline was based on a systematic review of published studies of patients undergoing total hip and total knee arthroplasty to prevent pulmonary embolism.2 The guideline found no difference in the pulmonary embolism rate, death rate, or death related to bleeding from prophylaxis among different thromboembolic prophylactic measures1 (Table 1). The Surgical Care Improvement Program (SCIP) of the Centers for Medicare and Medicaid Services (CMS) was initiated in an attempt to minimize venous thromboembolic disease and includes pay-for performance programs. This program has focused additional attention on thromboembolic disease. Specifics of the basic guidelines will be presented later in this chapter. A 2008 study determined the incidence, risk factors, and long-term sequelae of postoperative hematomas requiring surgical evacuation after primary total knee arthroplasty and pointed out the potential for adverse sequela of anticoagulation.3 The authors found a significantly increased risk of the development of deep infection and/or subsequent major surgery in patients who returned to the operating room within 30 days after the index total knee arthroplasty for evacuation of a postoperative hematoma. The authors concluded that these results support all efforts to minimize the risk of postoperative hematoma formation. Consequently, when patients are managed with pharmacologic prophylaxis it is important to prevent the development of a postoperative hematoma, to monitor for the development of a hematoma, and to practice techniques that will minimize its occurrence. One study found that patients treated with aspirin or warfarin were somewhat less likely to have associated bleeding complications than were patients treated with low-molecular-weight heparin (LMWH) or subcutaneous heparin.4