Current evidence is not clear about whether factors other than a history of previous venous thromboembolism increase the risk of venous thromboembolism in patients undergoing elective hip or knee arthroplasty and, therefore, we cannot recommend for or against routinely assessing these patients for these factors.

Rationale
Patients undergoing elective hip or knee arthroplasty are at high risk for venous thromboembolic disease (VTED). Only one risk factor, previous history of VTED, has sufficient evidence indicating that some of these patients may be at even higher risk.

The relevant evidence comes from two studies that evaluated patients with a personal history of VTED – one of medium and one of low strength. The Pedersen study of over 68,000 patients found a relative risk of 8.1, and the Warwick study of over 14,000 patients found a hazard ratio of 4.92 for post-operative VTED in patients with a previous history of VTED (see Table 20 for a summary of the results of these studies).

Twenty-nine studies addressed whether patients with one or more potential risk factors, other than previous VTED, have higher rates of VTED. The list of potential VTED risk factors for which we sought evidence is listed in Table 19. The studies were all of low or very low quality (see Table 49 in Appendix XIII for a summary of our appraisal of the quality and applicability of these studies). A statistically significant increase in VTED resulting from these other risk factors that confer an increased risk of VTED in surgeries other than primary hip or knee arthroplasty was not found in studies of hip or knee arthroplasty patients. This might be because these other VTED risk factors confer a lower overall risk than primary hip or knee arthroplasty surgery itself. Therefore, their effects may not be seen against the relatively high background risk already being experienced by patients receiving elective hip or knee arthroplasty. Therefore, we are unable to recommend further risk stratification based on these factors.

No data specific to hip or knee arthroplasty were found addressing many potential risk factors, and in many instances where it was found, it was of very low quality and it was contradictory (see Table 19 for a summary of the results of these studies and Table 21 for a detailed presentation of their results). Data from patients undergoing surgical procedures other than primary hip and knee arthroplasty were found also of very low quality (Table 23) and therefore were unreliable. We excluded some of the studies we retrieved to address this recommendation. These studies, and the reasons for their exclusion are listed in Appendix XIV, Table 58.
  1. Eriksson BI, Kalebo P, Anthymyr BA, Wadenvik H, Tengborn L, Risberg B. Prevention of deep-vein thrombosis and pulmonary embolism after total hip replacement. Comparison of low-molecular-weight heparin and unfractionated heparin. J Bone Joint Surg Am 1991;73(4):484-493.
  2. Guijarro R, Montes J, San RC et al. Venous thromboembolism and bleeding after total knee and hip arthroplasty. Findings from the Spanish National Discharge Database. Thromb Haemost 2010;105(4).
  3. Joseph JE, Low J, Courtenay B, Neil MJ, McGrath M, Ma D. A single-centre prospective study of clinical and haemostatic risk factors for venous thromboembolism following lower limb arthroplasty. Br J Haematol 2005;129(1):87-92.
  4. Lowe GD, Haverkate F, Thompson SG et al. Prediction of deep vein thrombosis after elective hip replacement surgery by preoperative clinical and haemostatic variables: the ECAT DVT Study. European Concerted Action on Thrombosis. Thromb Haemost 1999;81(6):879-886.
  5. Leizorovicz A. Epidemiology of post-operative venous thromboembolism in Asian patients. Results of the SMART venography study. Haematologica 2007;92(9):1194-1200.
  6. Mahomed NN, Barrett JA, Katz JN et al. Rates and outcomes of primary and revision total hip replacement in the United States medicare population. J Bone Joint Surg Am 2003;85-A(1):27-32.
  7. Mahomed NN, Barrett J, Katz JN, Baron JA, Wright J, Losina E. Epidemiology of total knee replacement in the United States Medicare population. J Bone Joint Surg Am 2005;87(6):1222-1228.
  8. Mraovic B, Hipszer BR, Epstein RH, Pequignot EC, Parvizi J, Joseph JI. Preadmission hyperglycemia is an independent risk factor for in-hospital symptomatic pulmonary embolism after major orthopedic surgery. J Arthroplasty 2010;25(1):64-70.
  9. Memtsoudis SG, Besculides MC, Gaber L, Liu S, Gonzalez D, V. Risk factors for pulmonary embolism after hip and knee arthroplasty: a population-based study. Int Orthop 2009;33(6):1739-1745.
  10. Nathan S, Aleem MA, Thiagarajan P, Das DS. The incidence of proximal deep vein thrombosis following total knee arthroplasty in an Asian population: a Doppler ultrasound study. J Orthop Surg (Hong Kong) 2003;11(2):184-189.
  11. Pearse EO, Caldwell BF, Lockwood RJ, Hollard J. Early mobilisation after conventional knee replacement may reduce the risk of postoperative venous thromboembolism. J Bone Joint Surg Br 2007;89(3):316-322.
  12. Pedersen AB, Sorensen HT, Mehnert F, Overgaard S, Johnsen SP. Risk factors for venous thromboembolism in patients undergoing total hip replacement and receiving routine thromboprophylaxis. J Bone Joint Surg Am 2010;92(12):2156-2164.
  13. Ryu YJ, Chun EM, Shim SS, Kim JS, Kim YH. Risk factors for pulmonary complications, including pulmonary embolism, after total knee arthroplasty (TKA) in elderly Koreans. Arch Gerontol Geriatr 2010.
  14. Soohoo NF, Zingmond DS, Lieberman JR, Ko CY. Optimal timeframe for reporting short-term complication rates after total knee arthroplasty. J Arthroplasty 2006;21(5):705-711.
  15. Soohoo NF, Farng E, Lieberman JR, Chambers L, Zingmond DS. Factors that predict short-term complication rates after total hip arthroplasty. Clin Orthop Relat Res 2010;468(9):2363-2371.
  16. Warwick D, Friedman RJ, Agnelli G et al. Insufficient duration of venous thromboembolism prophylaxis after total hip or knee replacement when compared with the time course of thromboembolic events: findings from the Global Orthopaedic Registry. J Bone Joint Surg Br 2007;89(6):799-807.
  17. White RH, Gettner S, Newman JM, Trauner KB, Romano PS. Predictors of rehospitalization for symptomatic venous thromboembolism after total hip arthroplasty. N Engl J Med 2000;343(24):1758-1764.
  18. Won MH, Lee GW, Lee TJ, Moon KH. Prevalence and Risk Factors of Thromboembolism After Joint Arthroplasty Without Chemical Thromboprophylaxis in an Asian Population. J Arthroplasty 2011.
  19. White RH, Zhou H, Romano PS. Incidence of idiopathic deep venous thrombosis and secondary thromboembolism among ethnic groups in California. Ann Intern Med 1998;128(9):737-740.
  20. Bahl V, Hu HM, Henke PK, Wakefield TW, Campbell DA, Jr., Caprini JA. A validation study of a retrospective venous thromboembolism risk scoring method. Ann Surg 2010;251(2):344-350.
  21. Beksac B, Gonzalez D, V, Salvati EA. Thromboembolic disease after total hip arthroplasty: who is at risk? Clin Orthop Relat Res 2006;453:211-224.
  22. Frizzelli R, Tortelli O, Di C, V, Ghirardi R, Pinzi C, Scarduelli C. Deep venous thrombosis of the neck and pulmonary embolism in patients with a central venous catheter admitted to cardiac rehabilitation after cardiac surgery: a prospective study of 815 patients. Intern Emerg Med 2008;3(4):325-330.
  23. Fujita S, Hirota S, Oda T, Kato Y, Tsukamoto Y, Fuji T. Deep venous thrombosis after total hip or total knee arthroplasty in patients in Japan. Clin Orthop Relat Res 2000;(375):168-174.
  24. Gandhi R, Razak F, Tso P, Davey JR, Mahomed NN. Metabolic syndrome and the incidence of symptomatic deep vein thrombosis following total knee arthroplasty. J Rheumatol 2009;36(10):2298-2301.
  25. Hatef DA, Kenkel JM, Nguyen MQ et al. Thromboembolic risk assessment and the efficacy of enoxaparin prophylaxis in excisional body contouring surgery. Plast Reconstr Surg 2008;122(1):269-279.
  26. Hurbanek JG, Jaffer AK, Morra N, Karafa M, Brotman DJ. Postmenopausal hormone replacement and venous thromboembolism following hip and knee arthroplasty. Thromb Haemost 2004;92(2):337-343.
  27. Kosir MA, Kozol RA, Perales A et al. Is DVT prophylaxis overemphasized? A randomized prospective study. Journal of Surgical Research 1996;60(2):289-292.
  28. Keeney JA, Clohisy JC, Curry MC, Maloney WJ. Efficacy of combined modality prophylaxis including short-duration warfarin to prevent venous thromboembolism after total hip arthroplasty. J Arthroplasty 2006;21(4):469-475.
  29. Lemos MJ, Sutton D, Hozack WJ, Balderston RA, Booth RE, Jr., Rothman RH. Pulmonary embolism in total hip and knee arthroplasty. Risk factors in patients on warfarin prophylaxis and analysis of the prothrombin time as an indicator of warfarin's prophylactic effect. Clin Orthop Relat Res 1992;(282):158-163.