VENOUS THROMBOEMBOLISM AFTER PRIMARY JOINT REPLACEMENT

Abstract

In response to the recent publication in April 2007 of NICE guidelines on venous thromboembolism, we report our practice and experience of VTE in adult hip and knee arthroplasty.

It is generally agreed that the 2 major complications of VTE are sudden death as a result of pulmonary embolism and post thrombotic syndrome. NICE guidelines make 2 assumptions:

1. That chemical and mechanical prophylaxis can reduce these complications

2. That Orthopaedic surgery, in particular elective Primary Joint Replacements are particularly high risk procedures with respect to these 2 complications.

We have studied a large cohort of patients who had Aspirin only as chemical prophylaxis to determine the incidence of clinical thromboembolism before and after discharge and the mortality from PE at 90 days. We performed a prospective analysis of consecutive patients undergoing primary total knee and hip replacement from November 2002 to November 2007. In total 2050 patients had total knee replacement and 2203 patients had total hip replacement. All patients were treated at one specialist centre under the care of one surgeon. Data was complete and accurate for all patients at 90 days post-operatively.

Standard practice was the use of 150mg Aspirin from Day 1 post-operatively for a total of six weeks combined with spinal anaesthesia and early mobilisation.

The overall rate for Fatal Pulmonary embolism 0.07% (3/4253), overall death rate 0.3%(13/4253), for treated non-fatal PE 0.66% (28/4253) and for treated above knee DVT was 0.33%(14/4253).

Our data suggests that fatal pulmonary embolism is not common and does not account for most deaths following total hip and knee arthroplasty. We suggest there is no evidence that chemical/mechanical prophylaxis reduces the risk of sudden death from PE following elective primary joint replacement and with modern surgical practice elective hip and knee replacement should no longer be considered high risk procedures.