Anticoagulation Guidelines Orthopedic Procedures

Thromboembolic Risks

It is well documented that the risk of venous thromboembolism after orthopedic surgery is very high. ALL patients undergoing these surgeries are anticoagulated after surgery.

The thromboembolic risk profile is the primary determinant of whether bridge therapy with heparin or enoxaparin is necessary during the reversal of chronic anticoagulation pre-procedure. In all cases, the postoperative pharmacologic regimen must balance the risk of bleeding with the need for thromboembolic prophylaxis.

High risk procedures

  • Spine fracture with paralysis
  • THA (Total hip arthroplasty)
  • TKA (Total knee arthroplasty)
  • Hip fracture

Intermediate risk procedures

  • Multi-trauma
  • Acetabular/pelvic fracture

Low risk procedures

  • Arthroscopic surgery

Bleeding Risks

The risk of postoperative wound hemorrhage must be estimated to establish a safe protocol for postoperative resumption of anticoagulation.

High risk procedures

  • Extensive spinal procedures

Intermediate risk procedures

  • Total joint arthroplasty (THA and TKA)  

Low risk procedures

  • Arthroscopic procedures
  • Lumbar discectomy

General Recommendations for Pre-Procedure Warfarin Management

Target INR for elective orthopedic procedures is <1.3. Warfarin is generally held for 5 days prior to surgery.


Perioperative Management of Chronic Anticoagulation in Orthopaedic Surgery. J Am Acad Orthop Surg, Vol 18, No 12, December 2010, 729-738.


Special thanks to Scott Ball, MD for his expert guidance.