Editorial Current Vascular Pharmacology, 2011, Vol. 9, No.

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Editorial
An Update on Venous Thromboembolism in Trauma, Orthopaedic and
Reconstructive Surgery
Venous thromboembolism (VTE) including lower limb deep vein thrombosis (DVT) and pulmonary embolism (PE) remain
important causes of peri-operative morbidity and mortality. This is particularly true following major lower limb and pelvic pro-
cedures. Pathogenesis is multi-fold and relates to intra-operative physical venous occlusion, direct and indirect damage to ves-
sel walls and generalized activation of the coagulation cascade secondary to surgical trauma [1]. Historical studies suggest that
without thromboprophylactic protection, such events are extremely common post-operatively, with reported rates of DVT as
high as 70% [1, 2]. These figures vary greatly however, and appear to be significantly influenced by a variety of factors. For
example, the very low rates reported in Asian studies suggest that ethnicity and genetic predisposition may play a major role [3-
5]. Whilst it has been demonstrated that a large number of orthopaedic patients develop calf vein thrombi intra-operatively, the
vast majority of these appear to resolve spontaneously without clinical consequence, removed by the body’s inherent fibri-
nolytic system [6]. It would appear that in only a small number of patients do these blood clots propagate causing obstruction of
local vasculature or pulmonary embolism. Reported rates of fatal PE are very low, probably less than 0.5% even in those not
receiving thromboprophylaxis, suggesting that small venous thromboses may not be as important as has previously been sug-
gested [7, 8].
In patients receiving perioperative low molecular weight heparin (LMWH), radiologically determined rates of DVT remain
as high as 13% following hip and 38% following knee replacement. Similar to the pattern seen in unprotected patients, the inci-
dence of clinically significant thrombosis appears to be far lower than this, probably less than 1%. Though rates of fatal pulmo-
nary embolism remain low they are little reduce from those seen in unprotected patients [8, 9]. The use of radiographically de-
termined thrombosis as a surrogate end-point for clinically relevant VTE (pulmonary embolism or post-phlebitic limb) in many
studies makes the literature difficult to interpret and has more recently been criticized. Furthermore, the majority of clinically
significant thrombotic events appear to occur following discharge from hospital, calling into question our understanding of the
natural history of the condition and current thromboprophylaxis protocols which are for the most part in-patient only [10]. This
has lead to increasing interest in the concept of prolonged post-discharge therapy. The parenteral route of administration for
LMWHs and regular testing required for Warfarin make this approach potentially troublesome. More recently however, several
new oral agents have been introduced that require no laboratory monitoring in order to maintain safe levels of anticoagulation
and it may be that these prove to be a solution to this problem [11-14]. As with any new intervention, the financial and clinical
implications of such an approach must be carefully considered prior to widespread implementation.
Therefore, despite extensive study of the subject and the publication of multiple guidelines, understanding of post-operative
VTE is far from complete and opinion as to the optimum prophylactic regime remains divided. Attempts to introduce national
protocols have proved controversial with some parties feeling that the suggested treatments are excessively expensive and in-
troduce a disproportionate risk of complication given the actual clinical risk presented by VTE [15, 16]. This special supple-
ment is intended as an update on current concepts in this field. It contains review articles, original data and meta-analysis in-
cluding papers discussing the use of fondaparinux, evidence for the use of low molecular weight heparins in orthopaedic prac-
tice, the timing of chemical thromboprophylaxis, potential targets for a new generation of anti-coagulants as well as current
evidence for thromboprophylaxis following bilateral total hip replacement, total knee replacement, pelvic trauma and non-
cardiac vascular surgery. It should provide evidence to support decision making in this area and useful information regarding
potential future avenues of development.

REFERENCES
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Res 1994; 299: 25-30.
[3] Kim YH, Oh SH, Kim JS. Incidence and natural history of deep-vein thrombosis after total hip arthroplasty. A prospective and randomised clinical
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[6] Kearon C. Natural history of venous thromboembolism. Circulation 2003; 107: I22-30.
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Bone Joint Surg Am 2000; 82-A: 929-38.
[8] Murray DW, Britton AR, Bulstrode CJ. Thromboprophylaxis and death after total hip replacement. J Bone Joint Surg Br 1996; 78: 863-70.
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nous thromboembolism in patients undergoing elective hip or knee surgery. J Thromb Haemost 2007; 5: 1438-43.
[10] Milbrink J, Bergqvist D. The incidence of symptomatic venous thromboembolic events in orthopaedic surgery when using routine thromboprophy-
laxis. VASA Zeitschrift fur Gefasskrankheiten 2008; 37: 353-7.
[11] Yong CM, Boyle AJ. Factor Xa inhibitors in acute coronary syndromes and venous thromboembolism. Curr Vasc Pharmacol 2010; 8: 5-11.
[12] Gomez-Outes A, Lecumberri R, Pozo C, Rocha E. New anticoagulants: focus on venous thromboembolism. Curr Vasc Pharmacol 2009; 7: 309-29.
[13] Roberts LN, Arya R. New anticoagulants for prevention and treatment of venous thromboembolism. Curr Vasc Pharmacol 2010; 8: 373-82.
[14] Kanakaris NK, Nikolaou VS, Tosounidis T, Giannoudis PV. Fondaparinux for the prevention or treatment of venous thromboembolism related to
lower limb trauma: evidence today. Curr Vasc Pharmacol 2008; 6: 134-42.
2 Current Vascular Pharmacology, 2011, Vol. 9, No. 1 Editorial

[15] Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing
surgery. London, UK: (National Institute for Health and Clinical Excellence) 2007.
[16] Cusick LA, Beverland DE. The incidence of fatal pulmonary embolism after primary hip and knee replacement in a consecutive series of 4253 pa-
tients. J Bone Joint Surg Br 2009; 91: 645-8.

Peter V. Giannoudis Panayotis N. Soucacos

Guest Editor – Current Vascular Pharmacology Co-Guest Editor – Current Vascular Pharmacology
Academic Department of Trauma & Orthopaedic Surgery Academic Department of Trauma & Orthopaedic Surgery
University of Leeds Attikon University Hospital
Clarendon Wing A, Great George Street University of Athens Medical School
Leeds LS1 3EX Athens
UK Greece
Tel: 0044-113-3922750 Tel: +30210-6280209
Fax: 0044-113-3923290 Email: psoukakos@ath.forthnet.gr
E-mail: pgiannoudi@aol.com