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Prevention of Symptomatic Pulmonary Embolism in Patients Undergoing Total Hip or Knee Arthroplasty

This clinical practice guideline was approved by the American Academy of Orthopaedic Surgeons. Approximately four AAOS Clinical Practice Guidelines will be developed per year, with summaries regularly presented in the Journal of the American Academy of Orthopaedic Surgeons. This guideline summary is first of the series.

Dr. Johanson is Professor and Chair, Department of Orthopaedic Surgery, Drexel University College of Medicine, Philadelphia, PA. Dr. Lachiewicz is Professor of Orthopaedics, University of North Carolina School of Medicine, Chapel Hill, NC. Dr. Lieberman is Director, New England Musculoskeletal Institute, and Professor and Chairman, Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT. Dr. Lotke is Professor, Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia. Dr. Parvizi is Director of Clinical Research, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia. Dr. Pellegrini is James Lawrence Kernan Professor and Chair, Department of Orthopaedics, University of Maryland Medical Center, Baltimore, MD. Dr. Stringer is Orthopaedic Surgeon, Colorado Springs Orthopaedic Group, Colorado Springs, CO. Dr. Tornetta is Professor, Vice Chairman, and Residency Program Director, Department of Orthopaedic Surgery, Boston University School of Medicine, and Director of Orthopaedic Trauma, Boston Medical Center, Boston, MA. Dr. Haralson is Executive Director of Medical Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL. Dr. Watters is Orthopaedic Surgeon, Bone and Joint Clinic of Houston, Houston, TX.

Dr. Johanson or a member of his immediate family is affiliated with the publications Journal of Arthroplasty and Journal of Bone and Joint Surgery American; has received royalties from Exactech, Inc; serves as a paid consultant to or is an employee of Stelkast; and has received research or institutional support from DePuy, Exactech, IsoTis Orthobiologics, and Zimmer. Dr. Lachiewicz or a member of his immediate family serves as a board member, owner, officer, or committee member of the Hip Society and the Southern Orthopaedic Association; is affiliated with the publication Journal of Orthopaedic Advances; has received royalties from Innomed; is a member of a speakers’ bureau or has made paid presentations on behalf of Covidien and DJO Global; serves as an unpaid consultant to Zimmer; and has received research or institutional support from Zimmer. Dr. Lieberman or a member of his immediate family serves as a board member, owner, officer, or committee member of the American Association of Hip and Knee Surgeons; is affiliated with the publications Journal of Arthroplasty, Seminars in Arthroplasty, and the Journal of the American Academy of Orthopaedic Surgeons; serves as a paid consultant to or is an employee of DePuy, Boehringer Ingelheim, Bayer HealthCare, and Scios; has received research or institutional support from Arthrex, DePuy, Tornier, Medtronics, Amgen, and Stryker; and has received nonincome support (such as equipment or services), commercially derived honoraria, or other non–research-related funding (such as paid travel) from the American Academy of Orthopaedic Surgeons, DePuy, Boehringer Ingelheim, Bayer HealthCare, and Amgen. Dr. Lotke or a member of his immediate family serves as a paid consultant to or is an employee of Bayer and DePuy; is affiliated with the publications Knee, American Journal of Orthopaedics, and Journal of Arthroplasty; and has received nonincome support (such as equipment or services), commercially derived honoraria, or other non-research-related funding (such as paid travel) from DePuy. Dr. Parvizi or a member of his immediate family serves as a board member, owner, officer, or committee member of SmartTech; is affiliated with the publications American Journal of Orthopaedics, Current Opinion in Orthopaedics, International Orthopaedics, Journal of Bone and Joint Surgery American and British, Journal of the American Academy of Orthopaedic Surgeons, and Orthopedics Today, and with the publisher SLACK; serves as a paid consultant to or is an employee of Stryker, and has received research or institutional support from Stryker. Dr. Pellegrini or a member of his immediate family serves as a board member, owner, officer, or committee member of the American Orthopaedic Association, the Association of Bone and Joint Surgeons, the Hip Society, the ACGME Residency Review Committee, the Kernan Orthopaedic and Rehabilitation Hospital, the Maryland Orthopaedic Association, the Knee Society, and the AAMC Council of Academic Specialties Administrative Board; is affiliated with the publications Clinical Orthopaedics and Related Research, and Journal of Bone and Joint Surgery American; has received royalties form DePuy; is a member of a speakers’ bureau or has made paid presentations on behalf of DePuy; serves as an unpaid consultant of National Institutes of Health, Province of Ontario, Canada; and has received research or institutional support from the Journal of Bone and Joint Surgery American, AO, DePuy, Johnson & Johnson, National Institutes of Health, Novartis, Smith & Nephew, Stryker, and Synthes. Dr. Tornetta or a member of his immediate family is affiliated with the publication Orthopedics Today and the publisher Wolters Kluwer Health; has received royalties from Smith & Nephew; serves as a paid consultant to or is an employee of Smith & Nephew; has received research or institutional support from Smith & Nephew; and has stock or stock options held in Exploramed. Dr. Haralson or a member of his immediate family serves as a paid consultant to or is an employee of Medtronic Sofamor Danek, and has stock or stock options held in Allmeds. Dr. Watters or a member of his immediate family serves as a board member, owner, officer, or committee member of the Bone and Joint Decade, the North American Spine Society, Intrinsic Therapeutics, the Work Loss Data Institute, and the American Board of Spine Surgery; serves as a paid consultant to or is an employee of Blackstone Medical, Medtronic Sofamor Danek, Stryker, Intrinsic Therapeutics, and McKessen Health Care Solutions; and has stock or stock options held in Intrinsic Therapeutics. Neither Dr. Stringer nor a member of his immediate family has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article.

This clinical practice guideline is based on a systematic review of published studies on the management of adult patients undergoing total hip replacement (THR) or total knee replacement (TKR) aimed specifically at preventing symptomatic pulmonary embolism (PE). The guideline emphasizes the need to assess the patient’s risk for both PE and postoperative bleeding. Mechanical prophylaxis and early mobilization are recommended for all patients. Chemoprophylactic agents were evaluated using a systematic literature review. Forty-two studies met eligibility criteria, of which 23 included patients who had TKR and 25 included patients who had THR. The following statements summarize the recommendations for chemoprophylaxis: Patients at standard risk of both PE and major bleeding should be considered for aspirin, low-molecular-weight heparin (LMWH), synthetic pentasaccharides, or warfarin with an international normalized ratio (INR) goal of 2.0. Patients at elevated (above standard) risk of PE and at standard risk of major bleeding should be considered for LMWH, synthetic pentasaccharides, or warfarin with an INR goal of 2.0. Patients at standard risk of PE and at elevated (above standard) risk of major bleeding should be considered for aspirin, warfarin with an INR goal of 2.0, or none. Patients at elevated (above standard) risk of both PE and major bleeding should be considered for aspirin, warfarin with an INR goal of 2.0, or none.

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