Rethinking Venous Thromboembolism Risk After Major Orthopedic Surgery - A Transient Threat or a Persistent Problem?

Sep 28, 2026

Commentary evaluates venous thromboembolism (VTE) risk after major orthopedic surgery, contrasting traditional guidance that risk returns to baseline after the immediate postoperative period with evidence suggesting longer persistence. It summarizes findings from analyses using UK Biobank data after hip and knee joint replacement, highlighting elevated VTE risk up to a decade. The discussion contextualizes these results with prior cohort and registry studies, including time-stratified hazard ratios and cumulative risk patterns across 30-, 90-, and multi-year follow-up windows.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages4

Reading Time10 min

AccessFree to download

Rationale for reassessing post-orthopedic VTE risk

Evidence from UK Biobank follow-up after joint replacement

Hazard ratios and long-term cumulative risk

Supporting studies and time-course patterns

Cohort and registry observations

Pathophysiology and clinical distinctions

Limitations and implications for risk framing

[https://doi.org/10.1016/j.rpth.2025.103271](https://doi.org/10.1016/j.rpth.2025.103271) COMMENTARY Rethinking venous thromboembolism risk after major orthopedic surgery: a transient threat or a persistent problem? Charlotte M. Story 1 | Lauren E. Merz2 | Jordan K. Schaefer2 1Division of Hematology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA 2Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA Correspondence Jordan K. Schaefer, University of Michigan, C366 Med Inn Building, 1500 E. Medical Center Drive, Ann Arbor, MI 48109, USA. Email: [jschaef@med.umich.edu](jschaef@med.umich.edu) Handling Editor: Professor Michael Makris The risk of venous thromboembolism (VTE) after major orthopedic surgery has been estimated to be 15% to 60% without prophylaxis [1,2] (Figure). Recent studies estimate the 30-day cumulative VTE risk after total knee or hip arthroplasty to be 1% to 1. 2% in patients prescribed pharmacologic prophylaxis but note that the risk of VTE remains elevated for at least 90 days after the procedure [3,4]. Most research assessing VTE risk after orthopedic surgery emphasizes 30-or 90-day risk, as longer time periods are more challenging to study, and it is presumed that VTE risk returns to baseline after the immediate postoperative period. According to Guidance from the International Society on Thrombosis and Haemostasis (ISTH), a risk factor is major when (1) the risk of recurrent VTE (when the risk factor occurred up to 3 months before the VTE) after stopping anticoagulation is half the risk of recurrent VTE if there was no transient risk factor or (2) a greater than 10-fold risk of having the first VTE [5]. Risk factors are considered transient when they are associated with a given exposure and the risk of VTE returns to baseline when that exposure is removed; major surgery is the classic example of a transient risk factor. Thus, orthopedic surgery with general anesthesia over 30 minutes has traditionally been regarded as a major transient risk factor for VTE. In this study, Wu et al. [6] challenge this paradigm by suggesting that VTE risk after major orthopedic surgery may not be so transient. This study analyzed data from the UK Biobank to evaluate long-term VTE risk after hip joint replacement (HJR) and knee joint replacement (KJR) [6]. The authors identified 18,984 HJR and 16,709 KJR cases. Included patients were matched with controls by age, sex, a VTE history, and a cancer history. The authors found a persistently elevated VTE risk up to a decade postsurgery. The adjusted hazards ratio (HR) for first VTE at 30 and 90 days was 24.10 (95% CI, 16.93- 34. 30) and 7.06 (95% CI, 5.01-9. 96) for HJR and 27.31 (95% CI, 19.67-37. 92) and 6.84 (95% CI, 4.72-9. 93) for KJR, similar to data from previously published studies [7,8]. Interestingly, at the 1-to 2-year time point, the HR remained mildly elevated after both procedures (after HJR: HR, 1. 60; 95% CI, 1.24-2.06; after KJR: HR, 1. 55; 95% CI, 1.20-1. 99). After 1 to 2 years, the HR continued to decline but remained elevated over matched controls through the 10-year follow-up. The 10-year cumulative risk of VTE was 6. 2%(95% CI: 5. 7%-6.7%) for HJR cases vs 3. 3% (95% CI: 3. 2%-3.4%) in the matched controls as well as 7. 5%(95% CI: 7.0%-8.0%) in KJR cases vs 3. 6%(95% CI: 3.4% -3. 7%) for matched controls. The article suggests that while the risk of first VTE is most significant in the first 90 days, it remains persistently, if mildly, elevated for up to 10 years following HJR/KJR. Supporting this claim, several studies have observed that an elevated risk for VTE may persist above population controls for longer than the conventional 3-month window. In 2015, a similar time-stratified, propensity score–matched cohort study was published examining VTE after total knee arthroplasty (TKA) or total hip arthroplasty (THA) [7]. The authors found the ex

FAQs

Why has VTE risk after major orthopedic surgery traditionally been viewed as transient?

Risk was historically considered transient because major surgery is a classic exposure; VTE risk was presumed to return to baseline after the immediate postoperative period.

What did the UK Biobank analysis suggest about long-term VTE risk after hip or knee replacement?

It found persistently elevated VTE risk up to a decade after surgery, with hazard ratios at 30 and 90 days and risk remaining mildly elevated beyond 1–2 years through long follow-up.

How do other studies support or refine the conventional 3-month risk window?

Prior time-stratified cohorts and national registry data reported an expected rise at 30 and 90 days but also observed sustained elevation in hazard ratios beyond 3 months, including effects persisting for years or up to 180 days depending on procedure and outcome.

Sep 28, 2026

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