Orthopaedic thromboprophylaxis

Abstract

Thromboprophylaxis remains a controversial subject. A vast amount of epidemiological and trial data about venous thromboembolism has been published over the past 40 years. These data have been distilled and synthesised into guidelines designed to help the practitioner translate this extensive research into 'evidence-based' advice. Guidelines should, in theory, benefit patient care by ensuring that every patient routinely receives the best prophylaxis; without guidelines, it is argued, patients may fail to receive treatment or be exposed to protocols which are ineffective, dangerous or expensive. Guidelines, however, have not been welcomed or applied universally. In the United States, orthopaedic surgeons have published their concerns about the thromboprophylaxis guidelines prepared by the American College of Chest Physicians. In Britain, controversy persists with many surgeons unconvinced of the risk/benefit, cost/benefit or practicality of thromboprophylaxis. The extended remit of the recent National Institute of Clinical Excellence thromboprophylaxis guidelines has been challenged. The reasons for this disquiet are addressed in this paper and particular emphasis is placed on how clinically-acceptable guidelines could be developed and applied.

Mechanical prophylaxis after hip fracture: what is the risk of deep vein thrombosis? A retrospective observational study

“…In addition, stockings carry a significant cost, particularly in respect of the nursing time associated with excluding contraindications before their application, and with ensuring they are properly applied and remain correctly positioned without complications. 29 30 Further study is necessary to determine the risk–benefit ratio and cost-effectiveness of compression stockings for the contralateral leg following hip fracture.…”

The provision of total hip replacement for displaced intracapsular hip fractures

“…Warwick et al reported various reasons for certain guidelines not being followed in orthopaedic surgery. 21 These included lack of awareness of the guidelines, adverse personal experience with a certain procedure for a specific group of patients, the practicality of implementation and conflicting evidence. The proportions of THR performed in eligible patients have increased since the start of the national hip fracture audit programme, 1 demonstrating that perhaps surgeons are becoming more aware of the guidelines and changing their practice.…”

Thromboprophylaxis for Deep Vein Thrombosis and Pulmonary Embolism after Total Joint Arthroplasty in a Low Incidence Population

“…No such guidelines exist in Asian countries and where they do exist they are not strictly adhered to27). Coupled with a low incidence are the risks involved with using pharmacological thromboprohylaxis28).…”

“…Though numerous guidelines exist, there is still lack of adherence27). Even in the US and UK where DVT prevalence is high, guidelines are not fully implemented51,52).…”