An Orthopod’s PerspectiveAn Orthopod’s Perspective

Adrian BeaumontConsultant Orthopaedic SurgeonSalisbury District Hospital

Size of Problem ? 25,000 deaths per year VTE in 40% to 60% joint replacements Fatal PE in 0.1% to 5%

Inconsistent thromboprophylaxis Joint registry shows increasing use of

mechanical and chemical methods

Hugh Owen Thomas 1834 - 1891

Fast Track Mobilisation No clear data on VTE risk Intuitively beneficial

Rudolf Virchov 1821 - 1902

Nice Guidelines 2010 Had orthopaedic input Risk assess Hip and knee replacements high risk Combined methods Oral agents (not aspirin) Duration ‘Opt out’ when bleeding risk

Evidence! Or Evidence?Cross trial comparisons

Criteria End points Definitions Sponsored? Statistics

Need Expert Interpretation

Anti-Embolism Stockings Often problematic for our patients

Wounds, swelling etc Restricted movement Large legs

Hip Fractures Very common High mortality Immobility Delay to theatre Age

Lower Limb Casts Evidence if risk ? UK lags behind Europe Risk assess or risk forgetting

Plymouth type scoring system LMWH prescribed at discretion Ongoing audit

Major Bleeding (EMEA) Fatal Bleeding Decrease Hb by 20 grams Transfusion 2 units blood Critical bleeding Leading to discontinuation At surgical site Leading to reoperation

Deep InfectionOften disastrousUsually means implant removal

Summary The importance VTE recognised We have some knowledge of efficacy Variable but increasing prophylaxis

The adverse effects must be considered Expert guidance needed There will be ongoing change

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