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Hip: A. C. Watts and I. J. Brenkel A postal survey of current thromboprophylactic practices of consultant orthopaedic surgeons in the treatment of fracture of the hip J Bone Joint Surg Br 2005; 87-B: 296-300 [Abstract] [Full text] [PDF]

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Reply from Mr Brenkel to Dr Heyburn

Ivan J Brenkel, Adam Watts   (19 May 2005)

Use of fondaparinux

Gary Heyburn   (16 May 2005)

National Audit on DVT prophylaxis for patients with fracture neck of femur

Chakravarthy U Dussa, Rajaganeshan R, Sahni V, Menon TJ   (10 May 2005)

Letter from A. Upadhyay

A Upadhyay   (8 April 2005)

Reply from Mr Brenkel to Dr Heyburn 19 May 2005
Ivan J Brenkel, Orthopaedic Surgeon , Adam Watts Send letter to journal: Re: Reply from Mr Brenkel to Dr Heyburn ivanbrenkel{at}yahoo.co.uk Ivan J Brenkel, et al.	Sir, I agree with Dr Heyburn that the problem with fondoparinux is that it has a long half-life. It should be administered six hours post-operatively. Although it can be given pre-operatively, this is not practical because of its long half-life. It is easier to use fondoparinux in an elective situation. I. BRENKEL, BSc, MB ChB, FRCS Ed Queen Margaret Hospital Dunfermline, UK.
Use of fondaparinux 16 May 2005
Gary Heyburn, Asociate Specialist Orthogeriatrician Royal Group of Hospitals, Belfast Send letter to journal: Re: Use of fondaparinux garyheyburn{at}supanet.com Gary Heyburn	Sir, Thromboembolism remains a major cause of morbidity and mortality in hospital patients.1 The ideal chemical thromboprohylactic agent has yet to be invented and all of the agents currently used have their own peculiar limitations. A side effect of increased bleeding will cause problems not only for the surgeon, but also for anaesthetists who are increasingly using spinal anaesthesia in older patients with hip fracture. Fondaparinux is recommended by the ACCP2 as a suitable thromboprophylactic agent, but Brenkel and Watt's survey shows that there are small levels of useage of this agent in the UK. They speculate that this may be because fondaparinux is a relatively new agent which has only just received its licence for chemical thromboprophylaxis. Another possible reason for the poor uptake of fondaparinux might be related to its long half-life. In the UK there can be long pre-operative delays for hip fracture patients. Fondaparinux, given in the pre-operative period, might contraindicate spinal anaesthesia due to the risk of spinal haematoma. This could be overcome by using a different agent pre-operatively but this would complicate any thromboprophylactic policy. The worst case scenario would be the use of a chemical thromboprophylactic agent which would further delay surgery in an already vulnerable group of patients. G. HEYBURN, MRCPI MRCGP DRCOG Royal Group of Hospitals, Belfast, UK. 1. House of Commons Health Committee. The Prevention of Venous Thromboembolism in Hospitalised Patients. Second Report of Session 2004-5. Feb 2005. www.parliament.uk/parliamentary_committees/health_committee.cfm 2. Geerts WH, Pineo GF, Heit J A, et al. Prevention of venous thromboembolism: the seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 2004 Sep;126(3 Suppl):338S–400S.
National Audit on DVT prophylaxis for patients with fracture neck of femur 10 May 2005
Chakravarthy U Dussa, Research Fellow Princess of Wales Hospital, Rajaganeshan R, Sahni V, Menon TJ Send letter to journal: Re: National Audit on DVT prophylaxis for patients with fracture neck of femur dussacu1{at}msn.com Chakravarthy U Dussa, et al.	Sir, We read with interest the article in the March 2005 issue by Watts and Brenkel. It is interesting to know that the use of thromboprophylaxis for the patient who has a fracture of the neck of the femur has significantly improved since the last survey done 25 years ago.1 This is in keeping with the literature on this subject, which has shown the benefit of prophylaxis for DVT over last two decades from Europe and America.2,3 A recent Cochrane review clearly shows the benefit of unfractionated heparin.4 We conducted a similar nation-wide postal survey in 2003, which was presented at the Annual Meeting of the British Trauma Society in 2003. However, our response rate (46.3%) was not as good as that of Watts and Brenkel. We recorded some interesting observations in our survey that were not covered by their study. We received 723 responses to the 1648 questionnaires sent. Of these, 628 consultants said that they carried out trauma surgery, which was very similar to Watts and Brenkel's findings, and 625 had an existing protocol for thromboprophylaxis in their department. Of the responses we received, all had a protocol in place. 76% used LMWH and the rest used unfractionated heparin and Fondaparin. Only 53% used chemoprophylaxis. The remainder used both chemo- and mechanical prophylaxis. Our survey also showed a lack of uniformity among our respondents as to when they would begin their prophylaxis. While Watts and Brenkel noted 51% started before the surgery, 25% did so after, and 6% started intra-operatively. We found that 66.3% started on admission, 9.2% upon induction, 19.6% six hours post-operatively and 4.9% 24 hours post-operatively. As to when one would discontinue the chemoprophylaxis, we found while 10.8% discontinued on mobilisation, 10.4% prior to discharge, 47.8% upon discharge and 24.3% six weeks post-operatively. Interestingly 6.7% firms continued long after six weeks. Nearly the same number of consultants used the TED stockings (413) as in the study by Watts and Brenkel. The intermittent compression devices were sub-divided into foot and ankle pumps (100) and Flowtoon boots (68). 115 firms used a combination of mechanical devices. 37.3% of consultants preferred using the mechanical devices up to six weeks after discharge. It was interesting to note 14.8% of firms used the devices for more than six weeks. The drug used for chemoprophylaxis has been the surgeon’s choice and varies from either unfractionated heparin, LMWH or Fondaparin. It is quite possible that lack of evidence in terms of prospective randomised trials could be a reason why surgeons vary so much as to the type and duration of the use of prophylaxis. It would be a good idea for the British Orthopaedic Association to issue guidelines regarding thromboprophylaxis in neck of femur fractures. C. U. DUSSA G. RAJA V. SAHNI T. J. MENON 1. Morris G K, Mitchell J R A. Prevention and diagnosis of venous thrombosis in patients with hip fractures: a survery of current practice. Lancet 1976;2:867-72. 2. Salzman EW, Harris WH. Prevention of venous thromboembolism in orthopaedic patients. J Bone Joint Surg [Am] 1976;58(7):903-13. 3. Risk of and prophylaxis for venous thromboembolism in hospital patients. Thromboembolic Risk Factors (THRIFT) Consensus Group. BMJ, 1992 Sep 5;305(6853):567-74. 4. Handoll HHG, Farrar MJ, McBirnie J, et al. Heparin, low molecular weight heparin and physical methods for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures. Cochrane Database of Syst Rev 2005;2.
Letter from A. Upadhyay 8 April 2005
A Upadhyay, SHO South Manchester University Hospital, Wythenshawe Send letter to journal: Re: Letter from A. Upadhyay uashish{at}hotmail.com A Upadhyay	Sir, I read this article with interest. This is a timely study calling for an establishment of uniform protocol for thromboprophylaxis in patients with orthopaedic conditions. A recent parliamentary health committee report1 has suggested that a large number of people die annually in the UK from causes related to venous thromboembolism. The overall response rate of 62% in this study is only a reflection of the general lack of interest by most consultants. This is in spite of the rising number of cases of litigation being faced on this account by orthopaedic consultants and hospitals. The direct correlation of the response rates of the consultants with the presence of clear departmental policy is also enlightening. It is heartening to learn that in Scotland at least there is much uniformity in prescribing thromboprophylaxis, perhaps as a result of specific SIGN guidelines2. It would add further relevance to the data obtained if we knew about the regimes being followed for patients receiving outpatient plaster treatment as well. There is ample evidence to suggest that deep vein thrombosis is a serious problem which is often ignored in ambulatory plaster cast treatment of lower leg injuries.3,4 The British Orthopaedic Association should form a working group to formulate universally applicable guidelines, which can be used for thromboprophylaxis including the hitherto overlooked field of lower leg injuries. A. UPADHYAY, South Manchester Univeristy Hospital, Wythenshawe, UK. 1. http://www.parliament.the-stationery- office.co.uk/pa/cm200405/cmselect/cmhealth/99/9908.htm (Accessed 4/4/05) 2. http://www.sign.ac.uk/guidelines/fulltext/62/section5.htm(Accessed 4/4/05) 3. Jorgensen PS, Warming T, Hansen K, et al. Low molecular weight heparin (Innohep) as thromboprophylaxis in outpatients with a plaster cast: a venografic controlled study. Thromb Res 2002 Mar 15;105(6):477-80. 4. Spannagel U, Kujath P. Low molecular weight heparin for the prevention of thromboembolism in outpatients immobilized by plaster cast. Semin Thromb Hemost 1993;19 Suppl 1:131-41.