**4.3.1 Mechanical**

162 Deep Vein Thrombosis

in contrast, recommend pharmacological thromboprophylaxis for up to 35 days after THA and for 10 to 35 days after TKA. Moreover, they recommend against the use of aspirin in

> **Recommendation Risk Reccommendation** *PE Bleeding*

> > Standard Standard

Elevated Standard

Elevated Elevated

thromboprophylaxis in patients undergoing elective hip or knee surgery. (Reference: Huo M. VTE prophylaxis after total joint arthroplasty: current challenges-potential solutions.

Over the past 5 years, quality measures have been proposed and put into clinical application to monitor compliance with best practice guidelines in VTE prophylaxis. The Surgical Care Improvement Project (SCIP) was created in 2006 with reduction of VTE being one of its four primary focus areas. The Center for Medicare and Medicaid Services (CMS) has declared postoperative VTE as a "never event." As such, the CMS will no longer reimburse the hospital the costs associated with these complications. Other agencies and consumer groups

Several important improvements have already occurred as a result of these outcome measures. Surgeons and administrators have collectively established hospital-wide or hospital system-wide prophylaxis protocols. They have also worked to establish training and education programs to deliver the best practice guidelines to all the staff involved in patient care. Several limitations still exist however. The AAOS and the ACCP guidelines should be modified to establish a consensus. Unmet needs and improvement in the safety profiles hopefully will be fulfilled by newer agents in clinical development (Huo, 2011a).

A summary of specific oral pharmacologic agents currently in clinical application for

Aspirin LMWH

**AAOS**

LMWH Warfarin Aspirin Warfarin Fondaparinux

Aspirin Warfarin None

Fondaparinux

this patient population.

**ACCP**

Fondaparinux Warfarin

*Current Orthopaedic Practice* 2011;22:193-197.)

have also declared VTE as a preventable complication.

**4.2 Quality measures** 

**4.3 Specific modalities** 

orthopedic patients is in Table 2.

LMWH Standard Elevated

Table 1. Summary of ACCP and AAOS recommendations for pharmacologic

Mechanical prophylaxis using sequential compressive devices (SCDs) or foot pumps can be used as a sole means of VTE prophylaxis. Their clinical efficacy and safety have been documented in multiple studies. This is particularly useful in a patient that is perceived to have an elevated bleeding risk (Geerts et al., 2008). In many practices, mechanical devices are often used in conjunction with pharmacological prophylaxis. Newer devices may be used in the outpatient setting upon hospital discharge. The clinical efficacy, safety, and compliance have been documented in a few studies. It is necessary to continue to follow larger cohorts of patients using outpatient mechanical prophylaxis alone to fully determine the efficacy and compliance.
