[Thromboprophylaxis in patients with previous thromboembolic disease who require major orthopedic surgery].

Postoperative thromboembolic risk depends on both the patient's predisposing factors and on the surgical procedure. Patients with an objective history of venous thromboembolism who require orthopedic surgery are considered to be at very high postoperative risk. However, no specific prophylactic guidelines have been established for this group. Surgeons and patients have to choose between deciding against surgery or accepting a very high possibility of thromboembolic complications. We believe that this group of patients should be treated with an intensive prophylactic protocol combining physical (impulsion foot pump), pharmacological treatment (low molecular weight heparin [LMWH] administered at therapeutic doses from the third postoperative day) and eventually mechanical methods (removable vena caval filter). This intensive prophylactic protocol has been employed in our hospital since 2003, when we initiated an observational, prospective study in 20 patients with a history of venous thromboembolism (VTE) undergoing major pelvic or lower limb orthopedic surgery. Eighteen patients received postoperative physical prophylaxis and 1 month of therapeutic doses of LMWH. Two patients also received mechanical prophylaxis with a removable vena caval filter. Systematic venography and pulmonary scintigraphy performed 1 month after surgery allowed the diagnosis and treatment of one asymptomatic deep venous thrombosis (DVT) and one asymptomatic pulmonary embolism (PE). Moreover, a massive thrombi retained by the removable vena caval filter was detected in another patient. There were no bleeding events leading to reoperation or deaths. Systematic application of our intensive prophylactic protocol for patients with a history of VTE was safe and effective in preventing thromboembolic recurrence after major orthopedic surgery.